2. NEW ADDRESS REQUEST FORM

   Complete applications for new addresses will be reviewed, and an address confirmation letter will be provided to the applicant. Addresses may not be issued on the day of the application

   
   

4. Required Information

   1. Completed Request Form

   2. Last Recorded Plat  mark location of structure/culvert on plat

   A copy of the last recorded plat can be requested from the Superior Court located at 700 N. Pine St. Springfield, GA. 31329

6. Upload Last Recorded Plat Here*
8. Applicant*
9. Date*
   Date
11. Email Address*
12. Phone Number*
14. Select*

    1. Owner

    1. Builder

    1. Other
16. If other, please describe
18. Mailing Address*
20. City*
21. State*
22. Zip Code*
26. Owner, if different from above
28. Email Address
29. Phone Number
31. Mailing Address
33. City
34. State
35. Zip Code
39. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
41. Owner's Electronic Signature*
45. I need a new 911 address for:*

    1. Commercial/Industrial Building

    1. Mobile Office

    1. Residence

    1. Other
47. If other, please describe
49. Property Location

    Road name for 911 addresses will be based on the driveway location. Provide correct road name, as seen on road signs.

51. Water Service*

    1. County Water

    1. Private Well

    1. Community Well
53. Waste Water Service*

    1. County Sewer

    1. Private Septic
57. OFFICIAL USE ONLY

    Tax Map & Parcel ______________________     Zoning District: _____________________ Total Acres: _____________________

    Frontage on County-maintained road?   Y  /  N   (private road, see below)

    Private Road Name:                                                                                                                                             Sign in place?  Y  /  N  

    # of lots currently accessing private road/easement:                                                                                                                               

    Proposed name of new private road:                                                                                                                                                       

    Location (beginning at / ending at)                                                                                                                                                          

    Reviewed by Planning & Zoning:       /      /       Initials:                              Reviewed by GIS:       /      /       Initials:                               

    Approved?    Y  /  N    If not, reason:                                                                                                                                                       

    
    

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59. Submit

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