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everett <br />,,e <br />City of Evet:+t <br />Sewer Application and Permit <br />No. 23130 DATE <br />Service Address S <br />Billing Address_ <br />City, State, Zip <br />Owner (Mortgagor) _ <br />Billing Name <br />Connection By <br />DESCRIPTION: <br />Lot ;,Y Block <br />4 <br />Plat <br />Unplatted Descriptfion <br />Type Permit: <br />Remarks: <br />SEE SKETCH ATTACHED <br />CHART NO(7- Z5 - 2--c — _ <br />r <br />9s <br />Utility Account No. <br />Permit Fee <br />Connection Charge(s) <br />Total <br />Si <br />Sewer District <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />Lateral <br />Abutting Lot Line <br />N, S, E, W. <br />Approved <br />City Engineer <br />Issued <br />Inspection <br />Date Inspected <br />No. 23130 <br />INSPECTION <br />