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fi CHART E�NO. <br />— <br />�L7' !V <br />City of Everett <br />Sewer Application and Permit <br />No. 23104 DATE — — <br />Service Address 6?'+���rr�"�� <br />Billing Address <br />City, State, Zip - <br />Owner (Mortgagor) — <br />Billing Name <br />Connection By - <br />Address — <br />Phone <br />DESCRIPTION: <br />Lot Block <br />Plat <br />Unplatted Description___ <br />T..-- t--.:�. <br />Remarks: <br />SEE SKETCH ATTACHED <br />Utility Account N <br />Permit Fee <br />Connection Charc <br />Total Fee <br />Signed <br />Customer <br />Sewer District <br />Monthly Sewer Service_ <br />Monthly Sewer Constr. <br />Trunk <br />Abutting Lot Line <br />N, S, E, W <br />Approved By <br />Engineer <br />Issued B <br />'2 <br />Inspection By <br />cZC%iJ �iC/4� -L <br />Date lnspected <br />No. 23104 <br />11- , iI']H <br />