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everett <br />Clty of Everett <br />Sewer Applicat <br />T <br />� <br />� O O <br />4 O O <br />: :� <br />.� «. <br />ion and Pe$�t� � <br />� ��� <br />NO. Z$ Z S G DATE �r 9�s� <br />�y� Utility Account No. <br />S6rvfC6 Adlre _ ."'''_ �• �.. M <br />Billinp Address �— <br />CRY� State� �P � �� ..■ �a��l — <br />Owner <br />Connection by <br />Address <br />Phone <br />�eoe� DeacriPtion: <br />Lot <br />Blodc <br />Plet — <br />Unplatted Desc�tbn: <br />CHART N0. <br />� a �os�;r9 <br />5-�3-9 � <br />Permit Fee $ 30.00 _ <br />Connection Charge <br />Trunk <br />Lateral <br />� <br />�' <br />Total Connectbn Charge $ <br />Utilfty Development Fee <br />Water S <br />Sewer $ <br />Tota1 Development Fee S <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W <br />Type of Pertnft Approved By <br />� ��= Issued By <br />Rema�ks - <br />_ Customer Sipnature ' <br />IMPOFiTANT! <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />ft. <br />Inspection By . �����*�'— - <br />Date Inspected S iu �'r - <br />INSPECTION <br />No. 28256 <br />