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Specific Locatio6 / Rural Address Request <br /> (Entire form must be filled out before staff can process the request) <br /> Property Owner 4 \ r�'�k�15 �' Date: )0-/C/0 IMPORTANT <br /> Applicants must provide a site <br /> Current Mailing Address: plan, drawn to a measurable <br /> 39 I q Cl ki 8 scale showing: <br /> Street - Lot lines & dimensions <br /> riLPO,r10 , S3 SS - 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 /> ,7/ )_ 4 '6 ,5 S - Any approved Driveway <br /> Permit information from the <br /> town or county <br /> Township / Section of Needed Address: <br /> Specific Area / Nearby Roa s (e.g., road names, distance to intersection, etc.): <br /> Cc y`c, <br /> Tax Parcel Number: OG/0 -16- -01614 . O <br /> PI 1_i <br /> Additional Information: /', ddr 1■:5 0-Q_-e...:1 S ems--, <br /> Office Use Only: Staff person: S Zoning Permit#:aflogpF 13 <br /> \ -)--S-S-70=- C14. 1-1 <br /> cL . 1-1 -F ,Y3-) ‘ = <br /> TT <br /> )-141-1 O <br /> s <br /> 41, <br /> I .,_ S'111'{ t,-` et /4, <br /> Approved Address)11 3 G kee P.,c0-\ I�J Date /n4/o 1 <br />