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everY�tt <br />City of Everett <br />Engineering Department <br />:B —30— tc �-5 <br />Sewer Application and Permit <br />NO. ..0258 Y DATE <br />t <br />Service Address <br />Billing Address 'i/ <br />City, State, Zip <br />Owner (Mortgagor) <br />Billing Name <br />Connection By <br />Address <br />Phone <br />Utility Account <br />Connection Permit Fee C" <br />Connection Fee <br />Total Fee <br />DESCRIPTION: <br />Lot o� <br />Block <br />Division or Addition lll�t�T7" tii' I✓ 1 /f <br />Sewer Dist <br />Remarks: % �•� , )/ `� %% / <br />S ✓ c.�'.t.•-t <br />�ou� <br />.J <br />SEE SKETCH ATTACHED <br />INSPECTION <br />Monthly Sewer <br />Monthly Sewer Constr <br />Approveu By_ <br />City Engineer <br />Issued <br />Connection By <br />Inspection Ely 212yL%3 _ <br />Date Inspected <br />