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everett <br />City oi Everett <br />Sewer Application and Permit <br />No.279�_1 DATE �-30- ia <br />Service Address '. _ � `� �1: i-1. �' � <br />Billing Address ` '"'- � ' <br />City, State, Zip _- , � / ._ , , <br />Owner ; , � � � <br />Connection by <br />Address <br />Phone - ` ' <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Type of Per:nit <br />Remarks _ <br />�� ��V ` �Q <br />I PORTANT! ��( yr <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8870 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />Permit Fee $ <br />Connection Charge <br />Trunk <br />CHART NO. <br />Lateral <br />Total Connection Charge <br />Utility Development Fee <br />Water <br />Sewer <br />Total Develepment Fee <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />l d /�dS�l� <br />��d�lfo� % <br />•` <br />Sewer Bond District — <br />Abutting Lot Lir.a <br />N, S, E, W— ft. <br />Approved By �.�`� <br />�'ssued ey — � { 1 � „ / l , i/, / �— <br />r <br />Customer Signature <br />Inspection Dy _ <br />Date Inspected <br />INSPGCiIOiV <br />No. 21911 <br />