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CHART N0. <br /> everetl <br /> e � � � <br /> � <br /> City oi Everett S�-✓r ro Cs:q.er..��c� 2/S/8� <br /> Sewer Application and Permit <br /> , <br /> N0. Q5179 DATE __; � <br /> Service Address � q �,I�Utility Account No. <br /> Billing Address - Permit Fee o�� <br /> City,State, Zip ' � ' � / Cannection Charge�s) <br /> Owner (Mortgagor) 1� �' ' ' � j` Total Fee � , 1 <br /> Billing Name ,�" ' ' � �--- ' . 1 , .� <br /> ! 1 <br /> Connection By `-- ' � <br /> ; � � .._^ _ — <br /> Address � � � - ' ' '— _ Signed <br /> Cuslomcr <br />� / . ,'1 �: � r <br /> Phone <br /> DESCRIPTION: Sewer District <br /> Lot Bloc ���� Monthly Sewer Service <br /> Plat <br /> Unplatted Description Monthly Sewer Constr. <br /> Trunk <br /> Type Permit: <br /> Lateral <br /> Remarks: <br /> Abutting Lot Line <br /> N, S, E, W ft. <br /> Approved By � `�, , � <br /> Cicv E�c��� <br /> lssUed By `" �"- �— <br /> Inspection By�y�R`�� <br /> Date Inspected //- ?'� <br /> SEE SKETCH ATTACHED NO. QS1T9 <br /> INSPECTION <br />