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everettl <br />e x- <br />City of [verett <br />Enpineering Department <br />,'���—� -�� i <br />��_zq-�--�M�4i �;,. <br />Sewer Application and Permit <br />rvo. 2075i DATE _:'` �', <br />,—.`, ; ,: <br />Service Address %�� � ��' �'� `�- ``-' <br />Billing Address � �����%��� <br />� <br />City, State, Zip �'-� C:�`-:'�.��"%% : L�—',• 7 <br />_ , <br />Owner (Mortgagor) - �-/��T1 %'� <br />Billing Name % %� ' �� <br />l.'tility Account Na <br />Connection Permit Fee v��' � <br />_ ,/� c-�.:�•'�� � ;�t : ( c. <br />Connection Fee_ <br />Total <br />f . �r� <br />%- ! ��' - • <br />Connection By , i i , ' � " � ' � <br />> <br />Address .'� %c )f=-f- -= 'r=/_=i', Signed <br />— C ' Customer <br />`r _!i •'' <br />�- • _ <br />`_'-� . " \ .. <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />SEESKETCH ATTACHED <br />I;�:.-,I-� �..I �,'i`: <br />Sewer District <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />Trunk <br />Lateral_ <br />Abutting Lot Li�e <br />N, S, E, W_ <br />Approved By <br />Ciry Engineer <br />I ssu ed <br />I nspectio�i <br />Date I <br />No. 20757 <br />� <br />