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everelt \ J - <br />� <br />City of Everett <br />Enpineering Department <br />� <br />l��- "��' s <br />V - 5 � � �/��� J <br />✓ <br />! <br />Sewer Application and Permit <br />NO. 21 O O.+4 D.4TE �;, ;. .,, <br />; <br />Service Address � � n/ ���{J' � �'(�'�U �v' <br />Billing Address -- <br />City, State, Zip � ' <br />Owner (Mortgagor) � � ` <br />Billing Name ' <br />Connection By ' <br />Phone <br />DESCRIPTION: <br />Lot <br />Block � <br />Division or Addition ' <br />Tvoe Permit: <br />Utility Account No._ <br />Connection Permit Fi <br />Connection Fee_ <br />Total Fee <br />Signed <br />cu:eortrer <br />i <br />Sewer District , <br />Monthly Sewer Service - <br />Monthly Sewer Constr. <br />SEE SKETCH ATTACHED <br />INSP�CTION <br />Abutting Lat Line <br />N, S, E, W, <br />Apprw�ed By_ <br />Ciry Engineer <br />I SSUCCJ <br />Inspection <br />Date 1 <br />9 <br />No. 21.001 <br />� <br />