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SIGNATURES <br /> CITY OF `'`,ate-S PLANNING OFFICIAL: <br /> ctc,i Arch <br /> (Print Name) ^ Pw L(Signature) <br /> PE <br /> LI <br /> a--112-aoDo (t 13orbcn Ave w 503 -�S97 - a-c,(a 9 <br /> DATE ADD�tESS ) O� ',?3 t i , TELEPHONE# <br /> * COUNTY PLANNING OFFICIAL <br /> (Print Name) PLANNING OFFICIAL(Signature) <br /> DATE ADDRESS TELEPHONE# <br /> *If necessary,depending upon city/county agreement on jurisdiction outside city limits but within UGB. <br /> G:\FORMS\SEPTIC\Application Packets\S-39 LUCS.doc MC:S-39 rev: 8/10,04/12 <br />