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r <br /> SIGNATURES <br /> CITY OF G G• -e 5 PLANNING OFFICIAL: <br /> ---ica.c.1 Psycker <br /> (Signature)(Print Name <br /> e ti-Li leecord <br /> (1 • i8 -20 (DI Snrbin Ave k,/ 563 , 897 -?-449 <br /> DATE ADDRESS 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 />