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everett <br />City of Everett <br />L�J ��� G� �ZG � 17 <br />•� � -1C� � J <br />�T <br />Sewer Ap�lication and Perm�t <br />N0. 28�8i DATE 3- l- �( <br />Service Address ��E' oP'�r�D Utility Account No. <br />Billing Address <br />City, State, Zip <br />Owner <br />Connection by � � � �� � � �11C,° hE� <br />Address <br />Phone <br />Legal Descripiion: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Permit Fee � _... <br />Connection Chary� <br />Trunk <br />$ <br />Lateral $ <br />Total Connection Charge $ <br />Utility Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />Sewer 9ond District — <br />Abutting Lot Line <br />N, S, E, W — <br />$ <br />$ <br />1t. <br />i <br />Type of Permit FI 1 Y' '• rlr' 52��-a/L Approved By <br />Remarks ,�ay+ Ta�—� - �'4`—' d Issued By —s��N �� � � �� Y — <br />� �j ��[ t.c.r, � • PvC. — <br />^ , ,�;� ' j� Customer Signature <br />7.��..�__ rP o f,,,,,,4-,,J �' b. �' � C� �P � <br />IMPARTANT! � 3� E 6/ M N �,8�� , <br />T <br />CALL 1•500-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />Inspection By � � g� <br />CALL 259-8610 FOR 1�lSPECTION <br />Date Inspected �� — <br />SE�E SKETCH ATTACHED No. 2 8 0 81 <br />�;U:,�tO>.`;��i�COP, <br />