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Specific Location / Rural Address Request <br /> (Entire form must be filled out before staff can process the request) <br /> Property Owner: Date: IMPORTANT <br /> Applicants must provide a site <br /> Current Mailing Address: plan, drawn to a measurable <br /> scale showing: <br /> Street - Lot lines & dimensions <br /> - Any existing or proposed <br /> ingress/egress to the property <br /> City, State, ZIP <br /> - Distance from lot lines to the <br /> Phone #/ Email Address: existing / proposed ingress <br /> - Any approved Driveway <br /> Permit information from the <br /> town or county <br /> Township/Section of Needed Address: <br /> Specific Area/ Nearby Roads (e.g., road names, distance to intersection, etc.): <br /> Tax Parcel Number: - - - <br /> Additional Information: <br /> Office Use Only:Staff person: Zoning Permit#: <br /> (circle below) [ � <br /> S--)N /E-->W �J ll J 5J <br /> Odd/ Even <br /> J70 <br /> Approved Address 174'? DCG� � 7i / Date c S /5 <br />