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everett <br />� <br />City of Everett <br />Engineering Department <br />�ewrer Application and Per�nit <br />N0. �: �1_ . J :i DATE <br />Service Address Utility Account No. <br />Billiny Address Connection Permit f <br />City, State, Zip Connection Fee_ <br />Owner (Mortgagor) Total Fee <br />Bi!ling Name _ <br />Con�ection By_ <br />Signed _ _ <br />Customer <br />Phone_ <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />Type Permit: <br />Remarks: <br />SEE SKETCH ATTACHED <br />Sewer D <br />Monthly Sewer Service — <br />Monthly Sevver Constr. <br />Tru <br />Abutting Lot Line <br />N, S, E, W. <br />Approved By <br />Ciry Enginccr <br />I SSl1 E(� <br />Inspection By�Y�•-'—� <br />Date I nspected / 1i� 5l � G <br />i <br />N O. �_ '� r j ..) <br />