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1 ..". 5lt�-.. <br />everett <br />e <br />City of ENerett <br />CHART NO. 4 30 ' 2�"� 'S <br />►2}sr�r� � _ � a r <br />Sewer Applicc�tion and Permit <br />►vo. 23951 <br />DATE ��� � � � � <br />, ,, _ � i - <br />Service Address _ f� � <br />.' � i -,,.�Y <br />Billing Address <br />, , <br />, ; �. <br />City, S[ate, Zip — <br />; <br />Owner (Mortgagorl " <br />� <br />Billing Name <br />Utility Account No. <br />;,_._._ <br />Permit Fee `� �'� — <br />Connection Charge(s) <br />r.- <br />Total Fee `' — <br />� <br />`� , c� <br />.�- <br />/ <br />Connection By <br />Signed <br />AddfeSS — Customer <br />Phone � <br />Sewer District <br />DESCRIPTION: <br />Lot Block � Manthly Sewer Service <br />Plat 1 ' <br />Unplatted Description Monthly Sewer Constr. <br />� __ �___:.. , <br />SEE SKETCH ATTACHED <br />INSPECTION <br />Lateral <br />4butting Lot Line ; ' ; <br />N, S, E, W" I—�_-- <br />Approved BY Ciry Engincer / <br />Issued BY_" <br />Inspection By �"'' � , <br />Datelnspected v , <br />No. 23951 <br />