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eveiett <br />Cit', of Everett <br />Engineering Department <br />Sewer Application and Purnit <br />No. 21257 DATE <br />Service Address — <br />Billing Address — — <br />City, State, Zip_ -- <br />Owner (Mortgagor) — <br />Billing Name <br />Connection By <br />Address —. <br />Phone -- <br />DESCRIPTION: <br />Lot _— <br />Block <br />Division or Additicn <br />Tvnn Permit <br />SEE SKETCH ATTACHED <br />INSPECTION <br />Utility Account No. <br />Connection Permit I <br />Connection Fee_ <br />Total Fee <br />/J00�6 <br />Signed .L r / <br />j Cusromer <br />Sewer District <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />Trunk --- <br />Lateral <br />Abutting Lot Line <br />N, S, E, W. <br />Approved By <br />City Engineer <br />Issued <br />P Ins echo^ By <br />Date Inspected Z �� <br />No. 21257 <br />0 <br />