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everelt ' <br /> � � ` � " �j ,� �,.. _ � <br /> � � <br /> '� �" n ���p�j �� <br /> r : �: �!! <br /> c�� of e�e►�tt j�' ' r ����� <br /> Enpineering Department � <br /> Sewer Applicateon and Permit :i ; n �_ 7 <br /> PJO. �i}':i '1 .� DATE — <br /> Service Address % _ 'i,Utility Account No. <br /> Billing Address. Connection Permit Fee <br /> City, State, Zip,' • � ' � Connection Fee <br /> Owner (Mortyagor) __ Total Fee <br /> Billing Name ' Y'��` <br /> Connection By � ' " � <br /> Address ' `" Signed <br /> cus+ortrer <br /> Phone <br /> DESCRIPTION: Sewer District . - <br /> �ot <br /> Monthly Sewer Service <br /> Bfock <br /> Division or Addition � Manthly Sewer Constr. <br /> Trunk <br /> Type Permit: � i: - <br /> Lateral <br /> Remarkr. - , . ! ':, � <br /> - ' Abutting Lot Line <br /> N� S, E, NI ft. <br /> Approved BY-- <br /> City Engincer <br /> Issued By <br /> I i i <br /> — I Inspection ESy "�"� 'J� � ' — <br /> �I Date Inspected_ � - j �� I-S <br /> a— <br /> SEE SKETCH ATTACHED N�• �' � ' �' ' .' <br />