L M B Form No.

GSD C-1

N ORIGINAL SURVEY

Cad/Pls/Gss
Surveyed Approved

Lot No. Patent No. Date

Decree No. Date LRC Rec. No.

OCT No. Dated Issued to
TCT No. Dated Issued to

PLAN OF LAND

AS SURVEYED FOR

SITUATED IN THE
RURBAN CODE :
BARANGAY OF : CAINGIN
MUN. / CITY OF : SAN RAFAEL
PROVINCE OF : BULACAN
ISLAND OF : LUZON
Containing an area of Sq. M.
PPCS - TM/PRS 92 ZONE NO.:
BEARINGS : TRUE
SCALE 1: 2000
0 20 40 60 80 100 150 200

I hereby certify that this is a correct plan of the survey made by me personally, or
under my direct supervision in conformity with the provision of RA 8560, as amen-
ded, otherwise known as "The Geodetic Engineering Act of 1998" and the rules and
regulations of the Department of Environment and Natural Resources.

I further certify that this plan accurately indicates the boundaries of the property
as pointed to me on the ground by the survey claimant or his authorized represen-
tative and/or based on the available legal and/or official technical documents and
that I assume full responsibility for the technical correctness of the survey and
accuracy of the monument setting.

Date of Survey
Geodetic Engineer

Republic of the Philippines

Department of Environment and Natural Resources
Lands Management Services
Region Office...III
CENTRAL LUZON Region
The survey plotted herein is found to be in order as per submitted survey returns
of the Geodetic Engineer and therefore recommended for approval.

CHIEF, Surveys & Mapping Division

Date Approved:

This approved plan, however, shall not be construed as title to the land.

Asst. Regional Director for Technical Services

Date Date Documents
Submitted / Remarks
Re-Submitted Returned Received by:

With my conformity

NOTE:
Land Owner
(FOR SIMPLE SUBDIVISION ONLY)
ADDITIONAL INFORMATION AFTER DATE OF APPROVAL

VERIFICATION FEE
Paid Under
O.R. No.
Date:
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