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SIGNATURES <br /> are.OF PLANNING OFFICIAL: <br /> r r-171Ct— <br /> (Print Name) ANNING OFFICIAI,(Signature) <br /> 6-676-16 :7--)e)G2tr) <br /> DATE AD)Rcss TEA IONR <br /> 97S7‘ <br /> COUNTY PLANNING OFFICIAL <br /> (Print Mum') PLANNIN( 011:1(1Al.(Sign:num) <br /> DATE ADDRESS nutplior4E <br /> if necessary.depending tipon eit,vienurny tonInnnent on jurisdiction monade rkt•limits hm within(Vit. <br /> riSFORMS)SEPTICIApplication Ruckts‘S-39 LIJCS.clort MC:S-39 rev: JW,(N/12 <br />