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a <br />everetl � _ <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />DATE <br />Service Address <br />Billing Address <br />City, State, Zip 4. rr <br />Owner (Mortgagor) <br />Billing Name_ twit <br />Connection By <br />Address `�`"i•' r "i� <br />DESCRIPTION <br />Lot <br />Utility Account No <br />•�-r. <br />Connection Permit Fee <br />Connection Fee <br />Total Fee — <br />Signed (;r',`fCf.l.(.�'.!"` <br />Customer <br />Block <br />Division or Addition /_'" / S %//�• <br />Sewer District _ <br />Monthly Sewer Service <br />Remarks: � � ;,; � <br />Monthly Sewer Constr. <br />SEE SKETCH ATTACHED <br />1!•ISPECTI0N <br />Approved By <br />City Engineer <br />Issued By -- <br />Connection By <br />Inspection By <br />Date Inspected <br />