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everett <br />Clty oi Everett <br />Sewer Application and Permit <br />No.28075 <br />Servfoa Address �� J C12��- <br />Billfng Address <br />City, State, Zip <br />Owner <br />Conneclion by � A� F i 1�'- e-Y�_ t f <br />Address <br />DATE 2 - � - 4 �. _ <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Descriptlon: <br />.:. • :. � � � I f � i <br />,, i <br />ii t . I. � . � <br />�, � <br />CALL 1-800-424-5555 46-HOURS <br />PRIOR TO OIGGING <br />CALL 259-8810 FOR INSPECTION <br />M.v,,.� G� a. ss ���,� 3�� <br />�� ' N �� �,� ,-.� A /�� �, <br />SEE�SKETCN ATTACHED <br />Utility Account No. <br />i <br />Permit Fee $ <br />Connection Charge <br />Trunk <br />Lateril <br />Total Connection Charge <br />Utiliry Development Fee <br />Watar <br />Sevrer <br />Total Development Fee <br />$ <br />$ <br />a <br />$ <br />$ <br />$ <br />Sewer Bond District <br />Aburiir�g Lot Line <br />N, g, E, yy ft. <br />Approved By <br />Issued By n � i�! �(� Y <br />Customer Signature <br />Inspection By <br />Date Inspected <br />uriurv e,i�unc <br />No.28075 <br />