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everett <br />� <br />City of Everett <br />Engineering & Community Services <br />Sewer Applicateon ar�d Permit <br />CHART NO.r�",/ "' �— ��`'� -� <br />�'�3'�� g <br />� <br />� 2�- ' <br />/�� <br />_,,,� -, ��% <br />N0. �" C � � ( '�� DATE � � _ r.l. <br />Service Address. '• `% � �l�" ` ' ' , '�� Utility Account Na <br />Billing Address Permit Fee <br />City, State, Zip_ Connection Charge <br />C,vner (Mortgagor�_ Total Fee_ <br />Billing Name <br />, <br />" .__-- <br />Connection By - <br />Address <br />Phone <br />DESCRIPTION: <br />Lot <br />Plat <br />Unplatted Descripti <br />� <br />� Signed � .. . � , � <br />Custoner <br />� <br />Sewer District � <br />Block � <br />Monthly Sewer Ser. �ce_ i <br />I <br />Monthly Sewer Con;tr. { <br />� <br />SEESKETCH ATTACHED <br />� INSPr'riii,;.� <br />. ' ", . , , <br />Abutting Lot Line <br />N, S, E, W <br />Approved By - � � <br />City Engineer <br />� / <br />Issued Bv! <br />Inspection By �f,'`����-,��� <br />Date Inspected ?/���j��/ <br />N0. __' �.' f �' <br />' �, _,•.a .. - <br />