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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 /> Current Mailing Address: Applicants must provide a site <br /> plan, drawn to a measurable <br /> scale showing: <br /> Street - Lot lines & dimensions <br /> - Any existing or proposed <br /> City, State, ZIP ingress/egress to the property <br /> - Distance from lot lines to the <br /> Phone # / Email Address: existing / proposed ingress <br /> - Any approved Driveway <br /> Permit information from the <br /> Township/ Section of Needed Address: town or county <br /> Specific Area / Nearby Roads (e.g., road names, distance to intersection, etc.): <br /> 1,c,X v.)So 1�c <br /> Tax Parcel Number: - - <br /> Additional Information: <br /> Office Use Only: Staff person: 1-1‘..- Zoning Permit#: <br /> • <br /> e e�� <br /> —7 I ,CI + InI6*7 Io 35 . E <br /> vP <br /> Sr, <br /> viS <br /> Approved Address I/ f 64.4. --Date 1 C;1 ;/sP\ 11 <br />