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everett <br />e <br />City of Everett <br />Enp�neerinp Dep�rtment <br />Sewer Application and Permit <br />NO. 21 � Q 5 DHTE �� %��� '� �'� ` <br />�--�%.- <br />����/� <br />� <br />47"_ zo .. �.-� -- 5 <br />Service Address " '� -_ Utility Account No. — <br />Billing Address Connection Permit Fee <br />City, State, Zip �� - "-' Connection Fee_ <br />Owner (Mortgagor) Total Fee <br />Billing Name <br />Connection By ' <br />Address _ Signed � <br />� customer � <br />Phone <br />DESCRIPTION: Sewer District <br />Lot � - <br />Block Monthly Sewer Service <br />Division or Addition iJlonthly Se;ti.r Constr. <br />r. -- ^--:-. <br />SEE SKETCH ATTACHED <br />INSP�CTION <br />Abutting Lot Line <br />N, S, E, W <br />Approved By <br />City En9ineer <br />ISSUCd BY � <br />Inspection By — <br />Datelnspected <br />rvo. 21395 <br />0 <br />