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everetf <br />City of Everett <br />� �,,, - <br />�,�� <br />S' <br />�� l zU_� _(3 <br />�:. � <br />n�oc`�I <br />p� S <br />Sewer Application and P�rmit <br />No. 2 8 C 71 DATE �- N' 4� <br />Service Address � 7 ��� �ti�� �" p Utility Account No. <br />Billing Address <br />City, State, Zip <br />Owner <br />Connection by _(_',y.t�r m r �-� F'��{— <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Piat <br />Unplatted Description: <br />Permit Fee $ <br />Connection Charge <br />Trunk <br />$ <br />Lateral � <br />Total Connect;on Ciiarye $ <br />Utiliry Development Fee <br />Wazer <br />Sewe; <br />Total Develupment Fee <br />Sewer Bond Disti ict — <br />Abutling Lot Line <br />N, S, E, W <br />$ <br />$ <br />E <br />T'ype o( Permit �L7�n � Q Approved By <br />Remarks � <br />� O Issued By �"�' �� 1�� Y <br />� Q� �� l ,�-7� /,�,�'] / 3 ,�� Customer Signawre <br />ON S.4/�'L+Z_- 5Ti4NC� P��� �oM /1'�4 �N � 2 <br />IINPORTANT! T � � � S, P , ,S- � � . <br />CALL 1-800-424-5555 48-tiOURS � �-�-�-�'L • <br />PRIGR TO DIGGING <br />CAL! 259•8810 FOR INSPECTION <br />SEE SiCETCH ATTACHED <br />ft. <br />�. �Q, oC �%XC,4(IA �aN _ <br />.1a8 : `�, of n1 N <br />Inspection By <br />Date Inspected �� �� � �� <br />No. 28071 � � <br />cusTor,�r_r cor-� 1 <br />