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everett <br />11 <br />City of Everett / ?� <br />Engineering Department <br />Sewer Application and Permit <br />NO. 10028p� DATE <br />Service Address 11 6 2 Z /TOL L <br />Billing Address__ <br />City, State, Zip_ <br />Owner (Mortgagor) <br />Billing Name__ <br />Connection By <br />UESCRIP' iON: <br />Lot _ <br />Block -- <br />Division or Addition_ <br />Remarks: <br />,. <br />n r- /J !1la s J <br />W •n I ce <br />r " <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />Connextion Permit Fee <br />Connection Fee_ <br />Total Fee <br />Signed_ <br />Customer <br />INSPECTION <br />Sewer District_ �S <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />Approved <br />Engineer <br />Issued By <br />Connection By <br />Inspection By <br />Date Inspected oz� 7r <br />