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everett <br />� <br />City of Evcrett <br />���er Applic�at�on and Permit <br />No. 23415 DATE _ <br />192P ✓irninia Aveatm <br />Service Address <br />Billing Address <br />City, State, Zip <br />Owner �Mortgayor) <br />Billing Name <br />Connection gy City pf !'oerett <br />Phone_ _ <br />DESCRIPTION: <br />lot Block <br />Plat <br />Unplatted Description <br />Type Permii: repair <br />Remark;: <br />CHART N0. �- �=�� �� � S <br />��,�„� <br />; <br />— I- - <br />Utility Account No. <br />Permit Fee none <br />Connection Charge(s) <br />� ot;d Fe�° nona <br />. -�,.i <br />Sigr�ed .. . <br />Sewer Disu �r.� <br />Monthly Seevar Servir.�� <br />Monthly Srwer Consti <br />Trunk__ <br />Latera�_ <br />�.buttina Lo� I_ine <br />SEESKETCH ATTACHED <br />;f��jc <br />1'�_?r. <br />Jt. <br />. . _: rr:;�: <br />pprova°d By <br />City EoBioeer <br />r.. 9ond <br />sued Bv _ _ <br />ispection By .�l � �/%%a a.t �� � <br />3te Inspected_ � /, /; _ <br />No. 2341 � <br />