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everen <br />� <br />City of Everett <br />Engineering Oenartment <br />5ewer Application cand Permit 1 <br />hn. �1_�3� DAT� <br />S/35 5ou.vD �VE <br />Service Address <br />Billing Address _ <br />City, State, Zip <br />Owner (Mortgagor) <br />Billing Name — <br />Connection By -- <br />Phone <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />Utility Account No. <br />Connection Permit I <br />Connection Fee_ <br />Total Fee <br />_ Signed Cusmme� <br />Sewer District_ __ <br />Monthly Sewer Serv;ce. <br />Monthly Sewer Canstr. <br />u <br />SEESKETCH ATTACHED <br />Abutting Lot Line <br />N, S, E, W. <br />Approved By_. <br />City Enginecr <br />Issued <br />Inspection By—,/,�� ` J�� <br />Date Inspected_ '' 3i �'� <br />/ N � � 'i, . <br />