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1 V;rett) <br />City of Everett <br />Engineering Department <br />Sever Application, and Permit <br />No. 21410 DATE <br />Service ,Address <br />Billing Address <br />City, State, Zip______ <br />Owner (Mortgagor)___ — <br />Billing Name <br />Connection By <br />Fnone <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />T,,n. D.—:.- <br />Utility Account No. <br />Connection Permit Fee <br />Connection Fee <br />Total Fee <br />Sign <br />Sewer District <br />Monthly Sewer Service <br />` Monthly Sewer Constr. <br />SEE SKETCH ATTACHED <br />INSPECTION <br />Abutting Lot Line <br />N, S, E, W ft. <br />Approved By <br />City Enginear <br />Issued By. <br />Inspection By—� <br />Date Inspected_ e'd /312C <br />No. 21410 <br />i <br />