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everett <br />ej <br />City of Everett d o <br />• M <br />Sewer Application and Pie it <br />NO. 28212 DATE _ k rlj j2, ,00, <br />Service Address _ 3419 M11— <br />Billing Address <br />City, State, Zip zvezatt_ A on2n, —_— <br />Owner — <br />Connection by <br />Address <br />Phone Ise »60 -- <br />LegJ Description: <br />r , <br />Lot <br />Block — <br />Plat <br />Unplatted Description: <br />Utility Account No. <br />CHART NO. -- <br />t� Pos{I�y <br />Permit Fee $— <br />Connection Charge <br />Trunk <br />$ <br />Lateral <br />$ <br />Total Connection Charge <br />$ <br />.Utility Development Fee <br />Water <br />$ <br />Sewer <br />,$ <br />Total Development Fee $ <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W -- <br />Type of Permit Approved By- <br />--aItfltR.Ya� <br />Remarks Issued By — <br />Customer Signature —_ <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 />Inspection By <br />Date Inspected <br />INIEPI-CTION <br />No. 28212. <br />ft. <br />