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everetl <br />�e <br />City of Ecerett <br />j Sewer Application and Permit <br />NO. `Z3��j1 DATE <br />Service Address_�L,� �+� �� <br />Billing Address - <br />� <br />CHART N0. �S "2�i�'S <br />'d�! I�-��-ar-�- <br />r��l <br />�( 5h� <br />� <br />Utility Account No. <br />Permit Fee_ . <br />�� <br />City, State, Zip__ _ i / /✓/) Connection Charge(s�_ -,. i; <br />Owner (Mortgagor) -- � _ Totai Fee . '' <br />Billing <br />Connection By _ , / ^ <br />� Address Si ned . " �� ' <br />9 ' ��..- / ,� <br />� , cu:�omc, <br />Phone � / '� <br />DESCRIPTIUN: SewerDistrict � ;� <br />Lot _,� Block ���— <br />Plat � �.< < � t�� Monthly Sewer Service_ '� <br />Unplatted Description. Nlonthly Sewer Constr. <br />� <br />Type Permit: / , <br />� Remarks: <br />S <br />SEESKETCH ATTACHED <br />, � , ����, <br />Abutting Lot Line <br />N, S, E, W, <br />APProved By_ /✓ I <br />Gry Engineer ' <br />I <br />Issued Bv �' . - � � <br />� <br />Inspection By / G1.�+-� L <br />Date Inspected_� - ��`�-�% <br />-----• <br />No. 23051 <br />