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everett <br />e <br />City of Everett <br />Engineering & Community Services <br />Sewer Application and Permit <br />NO. 2� 1 I �! DATE -, , �� <br />,, , <br />Service Address '�' ' ' �" �� . � <br />Billing Address <br />/ / <br />City, State, Zip "4� " j -'-:.�h. /! ?G / <br />Owner (Mortgagor) ' 1 �� - '' - <br />Billing Name <br />, <br />Connection By -� - %'-r•=..�--�:-- <br />. � � <br />Address _ <br />Phone <br />DESCRIPTION: <br />Lat � Block `"'� ��:�' <br />Plat ' — 2, ,. . _ � , . <br />Unplatted Descr <br />Type Permit: <br />CHART N0. �%0��� � <br />� s�r'� <br />9_�,�-�� . <br />Utility Account No. <br />Permit <br />� <br />Connection Charge(s) ` <br />Total Fee ` <br />� J , <br />� ' !!, fL-, . ,� <br />Signed � ` <br />cu:tomcr <br />u <br />SEESKETCH ATTACHED <br />liiSF'LCll��i�: <br />Sewer District <br />Monthly Sewer <br />Monthly Sewer Constr. <br />Lateral <br />Abuttiny ! oi Line <br />N, S, E, W <br />Approved By _ � ..a <br />Ciry Engineer ( <br />Issued <br />,,.�. _., <br />i �� / <br />Inspection By_ �'.�iL�� <br />Date Inspected��7 � <br />N0. <br />O <br />mm� <br />