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:3 <br />� Aft. <br />min <br />�1"I <br />171 <br />everett <br />�eysQ:zRs <br />City of Everett <br />Sewer Application and Permit. <br />NO. 28268 RATE _ +Q In, i4o+ <br />Service Address <br />Billing Address 9210— <br />City, Stale, Zip R rr vi game __ <br />Owner <br />Connection by Sam <br />Address <br />— <br />Address <br />Phone <br />Legal Description: <br />Lot S <br />Block -- <br />Plat 11011tv Viato-- <br />Unplatted Description: <br />Type of Permit now cannectLcm <br />Remarks ---- <br />IMPORTANTI <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />Permit Fee $ <br />Connection Charge <br />Trunk <br />CHART NO. -- — <br />TO POSTINGS i -Zz-gl <br />Lateral <br />Total Connection Charge <br />Utility Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />30.00 <br />$ 179 no <br />$ 4u co <br />$ 650.0o <br />Sewer Bond District Bo^a z — <br />Abutting Lot Line <br />N. S, E. W <br />Approved By — <br />Issued By <br />Customer Signature <br />Inspection By C� <br />Date Inspected���— 4� <br />INSPECTION <br />ND. 282G$ <br />