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SIGNATURES <br /> CITY OF l' & e,5 PLANNING OFFICIAL: <br /> (Print Name) C (Signature) <br /> Cf4 <br /> t 'D ( Soricr Ave.u/ 3 897 a-4(e1 <br /> DATE ADDRESS Gates,vi2 i 3 q TELEPHONE# <br /> * COUNTY PLANNING OFFICIAL <br /> $11 56(rhes <br /> (Print Name)) PLANNING OFFIC (Signature) <br /> 1)/13/-262-0 156 S;(l,crieh <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 />