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everett <br />e <br />City of Everett <br />Enpineering Department <br />Sewer Application and Permit <br />No. 21294 DATE <br />Service Address " � � <br />Billing Address <br />City, State, Zip � <br />Owner (Mortgagor) <br />Billing Name <br />Connection Bv — <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition. <br />Type Permit: <br />Utility Account No. <br />Connection Permit I <br />Connection Fee_ <br />Total Fee <br />Signed � ; � � .i %'�.�% — <br />Cusmmer <br />SEESKETCH ATTACHED <br />ii��sP�.r.T�lo� <br />Sewer District <br />Monthly Sewer Service. <br />Monthly Sewer Constr. <br />Lateral <br />Abutting Lot Line <br />N, S, E, W <br />Approved By <br />Ciry Engineer <br />I ssued <br />Inspection By <br />Datelnspected �% � — <br />No. 21294 <br />