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.. <br /> I Louisa_ S*. <br /> SIGNATURES <br /> CITY OF L„(a.��-% PLANNING OFFICIAL: <br /> AV-C.1\e,- <br /> (Print Name) PLANNING CIAL(Signature) <br /> 1 10` 66rb rt. e_ ,Wr 563 -8q 1'*)4,LQ' <br /> DA ADGF8 , t bQ c?3r'f_ 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 />