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everett I <br /> � <br /> City of Everett <br /> Engineering Oepartment <br /> SewQr Appl�cation and Permit � �,,� q$ <br /> N0. �� 1 � O / DATE <br /> D �` <br /> ..s� ✓ Sc-'N�io r:�� �f oP <br /> Service Address_ - ' Utility Account No. <br /> Billing Address Connection Permit Fee <br /> City, State, Z�p Connection Fee <br /> Owner (Mortgagor) '-� L�On.��42/) Total Fee <br /> Rilling Name_ <br /> Connection By <br /> Signed <br /> Ad(�f@55 — Customcr <br /> Phone — <br /> DE�CRIPTION: <br /> Lat � <br /> Block � <br /> Division or Addition ' " ' ' — <br /> Sewer District — -- <br /> Monthly Sewer Service <br /> Remarks: �T��% D� <br /> —� Monthly Sewer Constr. <br /> � � <br /> � �%� 4..,�._c. ' `.�-('`'` <br /> Approved By <br /> Gry Engincer <br /> (G �� <br /> Issued By <br /> r '=���—i�S�— Connection By ---- <br /> < y/� � <br /> j� Inspection By���� '`�"'� <br /> ~ �/� Date Inspected_!���—'' <br /> � <br /> .� <br /> SEE SKETCH ATTACHED <br />