PERMOHONAN LAYANAN PETA ANALISIS PENGGUNAAN TANAH

Kepada Yth.
Kepala Kantor Pertanahan Kota Palembang
Di tempat

Yang bertanda tangan di bawah ini:

Nama : ....................................................................................................................................................
Tempat, Tanggal Lahir : ....................................................................................................................................................
Nomor Identitas (KTP/SIM) : ....................................................................................................................................................
Alamat : ....................................................................................................................................................
HP dan Email : ....................................................................................................................................................

Dalam hal ini bertindak untuk diri sendiri / selaku kuasa:

Nama : ....................................................................................................................................................
Tempat, Tanggal Lahir : ....................................................................................................................................................
Nomor Identitas (KTP/SIM) : ....................................................................................................................................................
Alamat : ....................................................................................................................................................
HP dan Email : ....................................................................................................................................................

Dengan ini mengajukan permohonan Layanan Peta Analisis Penatagunaan Tanah untuk keperluan kegiatan
Kesesuaian Penggunaan Tanah terhadap RTRW atau RDTR.

Rencana Kegiatan/ Penggunaan dan Pemanfaatan Tanah.................................................................................................................

Keterangan tentang tanah yang dimohon:
1. Luas Letak : ....................................................................................................................................................
2. Desa/Kelurahan : ....................................................................................................................................................
Kecamatan : ....................................................................................................................................................
Kabupaten/Kota : ....................................................................................................................................................
3. Penggunaan Tanah saat ini : ....................................................................................................................................................

Untuk melengkapi permohonan dimaksud, bersama ini kami lampirkan:

1. FC KTP No ......................................................................................................................................................................................................
2. PBT (Peta Bidang Tanah) No ................................................................................................................................................................
3. .............................................................................................................................................................................................................................
4. .............................................................................................................................................................................................................................

Demikian permohonan ini kami sampaikan, dan kami bertanggung jawab atas kebenaran persyaratan
yang dilampirkan di atas.

Palembang, 202
Pemohon,

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