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everelt <br />� <br />City of Everett <br />Cngineering Oepartment <br />l�� 2 �—' � �c������ <br />� � <br />� I <br />5ewer application �and Permit <br />` � r' DATE <br />N O. 1-O L 7 C <br />Service Address <br />Billing Address ' <br />�_ <br />City, State, Zip ~ � ` � <br />,�, _ � <br />., .,., � <br />Owner (Mortgagor) - <br />� �� , .� <br />Billing Name <br />- _._ <br />Connection By ` —� ' — <br />Address_ `� �, � ' <br />Phone - - - - - - �' <br />DESCRIPTION: <br />Lot <br />Block , _ <br />Division or Addition — <br />Utility Account No._ <br />Connection Permit Fee_ <br />Connection Fee <br />Total Fee <br />Signed <br />Sewer Distnct <br />�,, - <br />Monthly Sewer Service '� - - � <br />'�i ___ _ <br />Jlonthly Sewer Constr._ <br />SEE SICETCH ATTACHED �.,� �,_�-,-�,�., <br />A(](]fOVB(j Bv CitY En9inccr <br />Issued B <br />Connection <br />r-- <br />Inspection8y � ���� � <br />Date Inspected � ���� � <br />