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cverett <br />e <br />city ,I r n, <br />Sewer Application and Permit <br />NO. 23071 <br />tr` <br />Service Address -- <br />Billing Address <br />City, State, up <br />owner (Mortgagor) <br />DATE <br />CHART NO. <br />9� s <br />_r <br />Utility Account No. <br />Permit Fee <br />Connection Charge(s) <br />Total Fee <br />Billing Name <br />i <br />Connection BY <br />Signed customer <br />Address <br />Phone -- f—' <br />Sewer District <br />DESCRIPTION: <br />-- <br />Block— Monthly Sewer Service <br />Lot — <br />{ plat Monthly Sewer Constr. <br />Unplatted Description <br />— Trunk <br />SEE SKETCH ATTACHED <br />INSPECTION <br />Lateral <br />butting Lot Line ft. <br />N, S, E. W <br />\pproved By cdv Engu.eef <br />Issued BY <br />VV <br />Inspection By <br />Date Inspected <br />.S ' 7 -7q <br />r <br />No. 23071 <br />