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• <br /> k S f . <br /> SIGNATURES <br /> CITY OF ClGi.. PLANNING OFFICIAL: <br /> —171/4-re-CA AttriAei <br /> (Print Name) PLANNING OFFICIAL(Signature) <br /> (94‘.3_ 11) l SOY b LK_ tA) 87c77?-1, <br /> ATE ADDRES n 6,7 3LitLo TELEPHONE# <br /> tettrs <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 />