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ri <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />ik <br />Service Address_ <br />Billing Address_ <br />City, State, Zip_ <br />Owner (Mortgagor)_ <br />Billing Name <br />Connection By <br />Address <br />DESCRIPTION: <br />Lot <br />Block — <br />Division or Addition <br />T.,...a PormiY <br />DATE <br />SEE SKETCH ATTACHED <br />INSPECTION <br />/Ar s d-OF- o <br />I <br />i i <br />Utility Account No. <br />Connection Permit I <br />Connection Fee_. <br />Total Fee <br />Signed—Cusromcr <br />Sewer District <br />Monthly Sewer Service. <br />Monthly Sewer Constr. <br />Lateral <br />Abutting Lot Line <br />N, S, E, W <br />Approved By — <br />Cliy Engineer <br />Issued <br />Inspection By L�— <br />Date I nspectedNo. 21332 <br />