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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: Gfe.50 Date:qb-9/9 1 IMPORTANT <br /> Current Mailing Address: Applicants must provide a site <br /> plan, drawn to a measurable <br /> OC C j f c ,L f`, ) scale showing: <br /> Street - Lot lines & dimensions <br /> M 1 i \ I Any existing or proposed <br /> LY Ingress/egress to the property <br /> City, State, ZIP <br /> - Distance from lot lines to the <br /> Phone #/ Email Address: existing I proposed ingress <br /> 6,-- 3 , /Q P_ S c� �;Q„� C o - Any approved Driveway <br /> Permit information from the <br /> Township I Section of Needed Address: town or county <br /> Specific Area / Nearby Roads (e.g., road names, distance to intersection, etc.): <br /> �SSca c' TS <br /> Tax Parcel Numberi1 C -V3 -gcy7�- c <br /> Additional Information: I i,f, -1-‹, P 007 ' e ric <br /> I <br /> Office Use On y.' Staff person: Pt ( (� p ning Permit#:� ( c1 <br /> °nom 1- BA V Reco v_ _SE"s� <br /> ) ssoc�f�J <br /> ma -'S51/$ (1 <br /> / 1\ <br /> c: , <br /> 31 <br /> Approved Address SS S,} 14-1 Date /CPO 9 <br />