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evs•ret;' <br />City of Everett - �• <br />Engineerirl Delmitment <br />Sewer Application and Permit <br />N0. t al .i 7 L DATE <br />Service Address <br />Billing Address <br />City, State, Zip <br />Ovrner (Mortgagor) <br />Billing Name <br />Connection By c <br />Address. - <br />F :.-,RIPTION: <br />Lot <br />Block <br />Division or Addition ' <br />Remarks: <br />(,,z e <br />rrOb CS G' <br />SEE SKETCH ATTACHED <br />63 <br />Utility Account No.. <br />Connection Permit F <br />Connection Fee_ <br />Total Fee <br />Signed <br />Customer <br />INSPECTION <br />Sewer District <br />Monthly Sewer Service — <br />Monthly Sewer Constr. <br />Approved By -- //I ) <br />City Engineer <br />Issued By <'- <br />Connection By. <br />✓ ' <br />Inspection By�-G��u�� <br />Date Inspected 3, <br />