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1 • <br /> SIGNATURES <br /> CITY OF G 5 PLANNING OFFICIAL: <br /> [ o cPirchw <br /> (Print Name) (Signature) <br /> C-' ► get o rckr <br /> ( 1 • a8 -,212aD (D i S�nrbin Aver 1j 563 . 897 -?-44? <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 />