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SIGNATURES <br /> CITY OF Gadi-ez PLANNING OFFICIAL: 1 �•. <br /> 41�GLr� ]�IrG� <br /> (Print Name) A (Signature) <br /> c� Ord Qom' <br /> - 4 a fl c L �J <br /> a l ( Sorb n U/ Sa3 8,7 <br /> DATE ADDRESS Geesi it 113q � TELEPHONE# <br /> * COUNTY PLANNING OFFICIAL <br /> S+h 5CI r he S <br /> (Print Name) PLANNING OFFICI (Signature) <br /> 1/ 3 l 2-02-0 5 15 5 S;I uar}oh Rd so3— 0-SoT <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 />