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CHART <br />everett <br />e <br />City of Everett <br />Sewer Application and Permit <br />No. 253n5 <br />Service Address_ <br />Billing Address_ <br />City, Sv te, Zip_ <br />Owner (Mortgagor) <br />Billing Name_ <br />Connection By_ <br />OU <br />Phone_ <br />DATE <br />DESCRIPTION: ,/ <br />Lot �Blo <br />Plat <br />Unplatted Description <br />Type Permit: <br />Remarks: <br />IMPORTANT! <br />CALL 1.800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259.8811 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />� o <br />Permit Fee <br />Connection Charge(s)— <br />Total Fee <br />% , 0 <br />S5 4 �!p o_- <br />Signed <br />Customer <br />Sewer District <br />Monthly Sewer Service. <br />Monthly Sewer Constr. <br />Trunk <br />Lateral <br />Abutting Lot Line �� <br />N, S, E, W //rr,�'i° ft. <br />Approved By C�' ✓� <br />Gay Engmeer <br />t <br />Issued By -- <br />(o.c6eIn-.4.� <br />Inspection — <br />Date lnspected 2-- .3 - V _ <br />No. 253U5 <br />INSPECTION <br />