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everett <br />� <br />,� <br />s <br />a <br />� <br />City of Everett x J�� <br />=� �s�= <br />Sewer Appli�a#ion and Permit <br />_ �..J: � <br />� � •S -�i 'J <br />NO. Z� Jr �. � DATE aaeshezll, l090 <br />SorviceAddress ^ ' ly *--- — <br />Billing Addross , <br />Ciry, State, Zip — <br />Owner a.rhy r+� <br />Conneclion by , , <br />Address »a» +� eo <br />�,. <br />Phone 35.+ �s�� --- <br />Legal Descdptfo,r <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Type of Permit <br />Remarks <br />IMPORTANTI <br />CALL 1-B00-424-5555 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 />� <br />.,�n% -i-c �Ilnrh,�r,� <br />$ <br />Lateral $ <br />Total Connection Charge $ <br />Utility Development Fee <br />Water <br />Sewer <br />Total Devriooment Fee <br />Sewer Bond Uistrict — <br />Abutting Lot Line <br />N, S, E, W <br />Approvad By —. <br />Issued By <br />Customer Signature <br />$ <br />Inspection By N �` `� <br />Date Inspected ���-9� <br />INSPECTfON <br />No. 28051 <br />n. <br />