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everett <br />�e <br />City of Everett <br />1 o q <br />j�',U <br />551� �5w 051 <br />Sewer Application and Permit <br />NO. 28086 DATE -')l <br />Service Address I S O e G, Q rrt hP r _ Utility Account No. <br />Billing Address <br />City, State, Zip <br />Owner <br />Connection by t f J n i 1= �1 a Y e— f t <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Type of Permit — �— t` <br />Remarks ; C C L1J0 <br />MA z, J .412 /l_i, ✓J G �,V P <br />IMPORTANT! <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Permit Fee $ <br />Connection Charge <br />Trunk $ <br />Lateral $ <br />Total Connection Charge $ <br />Utility Development Fee <br />Water $ <br />Sewer $ <br />Total Development Fee $ <br />Sewer Bond District <br />Abutting Lot Line <br />N,S,E,W <br />Approved By <br />Issued By T) n N ti 1110. r- <br />Customer Signature <br />/tom A ,.J 9 e e/6 <br />0/ 197-74 <br />Inspection By <br />Date Inspected <br />UTILITY BILLING <br />No.28086 <br />ft. <br />