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everett <br />e <br />City of E��erett <br />CHART N0. �' " � �� �� -� <br />Pa���� �=2� -e� <br />Sewer Application and Permit <br />No. 23641 <br />Service <br />Billing <br />City, S' <br />Owner <br />Billing <br />DATE /.�G7'� �5��%� <br />�„ <br />Connection By <br />Phone <br />DESCRIPTION: <br />Lot ? l - =.' '�7 Block � �ll <br />Pla[ � . ��-�� <br />Unplatted Description <br />Utility Account No <br />Permit Fee � s� <br />Connection Charge�s) <br />� �� <br />Total Fee ,� <br />_ _ ---- � <br />'t�.. <br />Signed <br />cu:tomer <br />SEESKETCH ATTACHED <br />IIJSPECTIUN <br />Sewer <br />Monthly Sewer <br />Monthly Sewer Constr. <br />Lateral <br />Abutting Lot Line <br />N, S, E, W, <br />Approved By <br />City f.ngineer <br />Issued B <br />Inspection By �- <br />Date Inspected Jl1L- �j�� <br />No. 23641 <br />