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�11t.L. l'a..C✓t rrr+ � <br />everett - <br />City of Everett <br />Engineering D artment <br />Sewer Application and Permit <br />NO. 21190y` DATE <br />Service Address �L ". `- Utility Account No. <br />34 Z( <br />Billing Address --- Connection Permit Fee_ <br />City, State, Zip o-'r Connection Fee <br />Owner (Mortgagor) I !- r t n Total Fee_ `<<' <br />Billing Name <br />Connection ey <br />Address Signed_ <br />Customer <br />Phone - <br />DESCRIPTION: Sewer District <br />Lot Monthly Sewer Service _ <br />Block <br />Division or Addition 4 t'+= 7:r Monthly Sewer Constr. <br />Trunk <br />Type Permit: _. <br />Remarks: <br />SEE SKETCH ATTACHED <br />JSPECTION <br />Abutting Lot Line <br />N, S, E, W. <br />Approved By <br />City Engineer <br />Issued BY <br />Inspection <br />Datelnspe <br />No. 21196 <br />11 <br />A <br />