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evereri <br />� I � <br />� � �� <br />City of Gverett <br />Engineering Oepartme:tt <br />S��wer Application and Permit <br />rv o. �%i- 0 0 71 <br />DATE . /-/. .' <br />, <br />Service Address <br />� ... ; � -i.�r,� >.'.. ! i�; I <br />,'= • ' ' <br />Billing Addre.;s '� <br />, a . - <br />City, State, Zip /.' (-= � � ; _� ; .,_. <br />Ovmer�Mortgagor) ' "� .':%'AJ i�' ( <br />�2415 <br />Utility Account No. f •� � ` � <br />, � <br />Connection Permit Fee -- � � — <br />-- :o ��, <br />Connection Fee -- •' - � -' '� ' <br />.� <br />Total Fee � `�' " � <br />,,.., <br />Billing Name �' % �' � ' � ___ <br />� <br />Connection By `� =''= - <br />� , - � : �_: <br />Address � F' ' ' � - Signed _ <br />� , , , . - ., : j �. Cusmmer <br />oti..,,� - ; i.' --� . �! ] � <br />DESCRIPTION: <br />Lot <br />, <br />Block <br />Division or Addition - "_ _ � '�' <br />� i ' --- Sewer <br />� <br />SEESKETCH ATTACHED <br />If�!SPCCTIOf`I <br />� <br />e <br />Monthly Sewer Service ` ' r-` ''` ` '� <br />� , -- <br />Monthly Sewer Constr. %'`' i _ <br />, . .j <br />Approved By <br />c��Y <br />Issued By % <br />Connection Bv <br />� . ;,,, ,. , <br />Inspection By K.�„r C� �� �lti°�"� <br />Date I nspected� i ���� '� '� <br />/, <br />1 <br />