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everett <br />C(ty of Everett <br />CHART NO <br />To PosTiHc__ —3- z <br />Sewer AppliCation and Permit <br />NO. Z$ S Z s DATE ��3 fr�_ <br />Service Address <br />, > . - . ne �ltility Account No. <br />BillingAddress �;�} �F�t�a 6t 6+� <br />City, State, Zip - Permit Fee $ <br />Owner „ n e n on onsc Connection Charge <br />Connection by _ <br />Address <br />Phone <br />Legal Description: <br />Lot _ <br />Block <br />Plat <br />Unplatted Description: <br />Type of Perr iit <br />. — <br />Remarks <br />IMPORTANT! <br />GALL 1-800-424-5555 48-HOURS <br />PRIOR TO OIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Trunk <br />Lateral <br />Total Connection Charge <br />Utiliry Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />Sewer Bond District <br />Abutting Lot Lfne <br />N, S, E, W _ <br />Approved By _ <br />Iss�ed By <br />Customer Signature <br />$ <br />$ <br />$ <br />$ <5B.&B <br />$ 1232 �0 <br />$ }672.96 <br />Inspection By -��� � <br />Date Inspected _ s /9 L- <br />INSPcCTION <br />rvo. 285c 6 <br />n. <br />