4 of 5
7/2020
_________________________________________ ___________________________
CERTIFIED PARCEL APPLICATION
TO BE COMPLETED BY APPLICANT
Folio Number(s): _____________________________________________________
Project Name: _____________________________________________________________________
Address of Property: _______________________________________________________________
Secon / Township / Range: ______________ / _________________/ _____________________
Project Acreage: _____________________________ Individual Well: _________________
Number of Lots: _____________________________ Individual Sepc: _______________
Land Use Designaon: _______________________ Public Water: ___________________
Zoning District: _______________________________ Public Sewer: ___________________
Legal Description of Parcel to be certified:
_____________________________________________________________________________________
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Legal Non-Conforming Status: ______________________________________________________
County-owned and Maintained Road (Name): ______________________________________
Easement: _________________________________________________________________________
Owner’s Name (Print): _____________________________________________________________
Address: ___________________________________________________________________________
City: _______________________ State: _________________ Zip: _________________
Telephone: ________________________ Email:
________________________
Applicant’s Name (Print): __________________________________________________________
Address: ___________________________________________________________________________
City: _______________________ State: _________________ Zip: _________________
Telephone: _______________________________ Email: ______________________________
Surveyor ’s Name (Print): ________________________________________________
Address: ___________________________________________________________________________
City: _______________________ State: _________________ Zip: _________________
Telephone: _______________________________ Email: ______________________________
I hereby certify that this application, as well as all plans submitted herewith, is a
truerepresentation of all facts concerning the proposed Subdivision.
Signa
ture of Owner or Authorized Agent Date
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