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everett <br />� <br />City of Everett <br />Enyineering Oepartment <br />/ /� ` / <br />�, _ ' ! ' <br />Sewer A�plication and Permit <br />N0. �5�� DATE <br />Ser:iceAddress `✓ �� ���������� <br />Billing Address <br />City, State, Zip <br />Owner �PAn-: , ,.: i . <br />Billing Name <br />Connection By <br />Phone <br />DESCRIPTION: <br />Lot <br />Block _ <br />Division or Addition <br />Utility Account Nc <br />Connection Permit <br />Connection Fee_ <br />Toial Fee <br />Signed _ <br />3 <br />SEE SKETCH ATTACHED <br />Sewer District <br />Monthly Sewer Service <br />Monthly Sewer Constr <br />Approved By — <br />Ciry Engincer <br />Issued <br />Connection <br />Inspectio� I <br />Datelnsoec <br />