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eyerett <br />��e <br />City of Everett <br />Engineering Department <br />/ � ��;;. V <br />{ ; I � � n / ,�.,�/f <br />, _ <br />;;: ; ; <br />' , <br />Sewer Application and Permit <br />No.�-0504 DATE _ - • � <br />:r ' �_ <br />Service Address ` ' � -' = <br />Billing Address " <br />City, State, Zip <br />Owner (Mortgagorl— ' � "' <br />Billing Name <br />Connection By <br />DESCRIPTION: <br />Lot <br />B1ack <br />Division or Additian <br />.- <br />_ Utility Account No._. <br />Conn�ction Permit Fee <br />Connection Fee <br />Total Fee — <br />. i <br />('L�,_ . '. ii' i <br />' � : ,.� $19fi�•C� �Cus�omcr � <br />. . __ - � ' � j � j I ;! ' � . • . <br />Sewer District <br />'Vlonthly Sewer Service - <br />Nonthly Sewer Constr. <br />:� <br />SEESKETCH ATTACHED <br />Approved BY ���� Engineer <br />Issued By — <br />Cannection 9y <br />Inspection By 7� Cs (� 5�a � <br />Date I nspected__ -3 `�,� � `� <br />