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Specific Locatio <br /> ti <br /> / Rural Address Request <br /> (Entire form must be fill d out before staff can process the request) <br /> Property Owner: CQ''c,\'1 FLIJe rS o „Date: ► `J///O 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 /> town or county <br /> Township / Section of Needed Address: <br /> /Qo)4)vry _l_l_ <br /> Specific Area / Nearby Roads (e.g., road names, distance to intersection, etc.): <br /> /1.4, y <br /> Tax Parcel Number:c1 01_ ) T _q3.aO ; 3 <br /> Additional Information: 'N'--v-) S FP <br /> 51-,0 J a t∎v,,_,--,..7 C C-c.e-s ‘•) q14 S " ‹.-rHy <br /> Office Use Only: Staff person: GA-- S Zoning Permit#:)JDO 9 t <br /> ZED/ r-D _ "sib <br /> 1-i- 0 ? / <br /> a � <br /> (4;1 <br /> CMS <br /> 9,ic,c, c HS <br /> Approved Address ti S6 Cl- Date 1 Q// <br />