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everen <br />e� <br />City of Everett <br />Engineering Department � <br />Sewer Ap�lication and Permit <br />� <br />NO. ��.li 1 ��' _ DATE � � <br />Service Address <br />Billing Address <br />City, State, Zip <br />Owner (Mortgagor) <br />Billing Name <br />Conner.tion By <br />Address J <br />Phone----- ---- -- <br />DESCRIPTION: <br />Lot <br />Block_ <br />Division or Addition <br />Remarks: r <br />Utility Acccun[ No. <br />Connection Permit f <br />Connection Fee <br />Total Fee <br />S gned <br />� <br />SEESKETCH ATTACHED <br />us�omrr <br />Sewer District_____ __ <br />Monthly Sewer Service <br />119onthly Sewer Cons'r._ <br />Approved B <br />cny <br />ISSU2C� <br />Connection By _ <br />Inspection By�fL��`u `' <br />Date Insper,ted 7 � i.3 <br />� 7 -- <br />