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everett <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />NO. 1029 <br />DATE <br />Service Address i Utility Account No. <br />Billing Address tit r"< T Connection Permit Fee <br />I r <br />City, State, Zip iC . _ -T, r 1 Connection Fee <br />Owner (Mortgagor)- Total Fee <br />Billing Name <br />Connection By <br />Signed <br />Customer <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />Sewer D <br />Monthly Sewer Service r <br />Monthly Sewer Constr. I ` <br />Approved By r-.t-v 10 it <br />City Engineer <br />Issued By. <br />Connection By <br />Inspection <br />Date Inspected <br />:m <br />SEE SKETCH ATTACHED <br />INSPECTION <br />I <br />