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�everett <br />Clty of Everett <br />Sewer Application and Permit <br />NO. 2 H O 4� DATE <br />Service Address , <br />Bilflng Address ' <br />Cfty, State, Zip �' '�'°' <br />Owner <br />Connection by <br />Address <br />Phone �..r <br />Legel Descxiption: <br />Lot <br />� <br />Plat <br />Unplatted DescriPtion: <br />Type o( Permit ■rs�auv. <br />Remarks <br />IMPORTANT! <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8850 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />CHART N0. <br />�o �os-�,�, <br />z_z�.�x' <br />Utiliry Account No. <br />I; %ti:l'r'0 1I:1..�Xf +JO(INN47f13 �CEk�t <br />/ <br />^(i043 <br />Fermit Fee $ 10.��_� jp � <br />Connection Charge <br />GL'CK tt0.U0 <br />Trunk a <br />Lateral a <br />Totel Connection Charge $ <br />Utility Development Fee <br />Water $ <br />Sewer a <br />Total Development Fee $ <br />Sewer Bond District <br />Abutting Lot Lfne <br />N, S, E, W n' <br />Approved By <br />Issued By <br />Cusromer Signature <br />Inspection By �ti 6 P lw�— <br />Date Inspected / z - 3 —y � <br />wsr�ccr�or� <br />No. 28043 <br />