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everett <br />� <br />City of Everett <br />Sewer Application and Permit <br />No. 23105 <br />DATE __ <br />CHART NO. r I �Z� <br />Service Address � ' ' '- ! ' - �— �' Utility Account Na. � ! '-� � ��' <br />Billing Address ' � � � � - ti � Permit Fee ' ' � � ' <br />�- / <br />City, State, 2ip � _ � ; � �. �=-1 i �• � /; '� ; ./ :: Connection Chargels) � � � ! i ; l "f I T.--�-: <br />Owner (Mortgagor�_ �-- �� � � - � _ � Total Fee_ _._____ __ <br />Billing Name' ' - �._ �_- .- � <br />C��nnection BY J—�---k, � ; . �. , � -- <br />� . / i ! i � - �--,._ �_� (_ ,. . <br />Address ' �-� Signed � - _______ _ <br />�� c�,iom�� — <br />Phone -� _ I _ <br />DESCRIPTION: Sewer District �. � <br />' l,=� 7' i..,' i r _ <br />Lot - Block`~''' <br />Plat � � " � � � _ . .-f._ Monthly Sewer Service__'_�`_._� '---- <br />Unplatted Description Monthlv Sewer Constr. <br />Trunk ' � <br />Lateral <br />SEESKETCH ATTACHED <br />ul;I�[ C i IUrd <br />Abutting Lot '_i,ie , , - . <br />N� S� E� W---{--- <br />Approved !3y_ � � ,' � , <br />Ciiy Enginccr <br />Issued BY �-- , -` <br />(—\ <br />Inspection By__'"i�'tiR�_�--� ��� ' � <br />Date Inspected_ S�:J1 � � �7 � <br />No. 23105 <br />