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everett <br />e <br />c�cy or e�eren <br />Engineering & Community Services <br />Sewer Application and Permit <br />N0. f ;' : ` :: •`) DATE /— ��- j Y <br />CHART NO �� y '� <br />l�a 5 T-G.: /..� <br />,_��-� q _ <br />,�� �c. <br />_----"- <br />Service Address �/-.' '� q- 3 1 �� . Utility Account No. <br />Billin Address-�-J� • � / � �' ��' <br />9 -' �2 i Permit Fee � � <br />� w <br />CitY, State, Zip . .c• , / / �;�� '�k i(7� <br />Owner (Mortgagor��=�_L,��-;- ,�� ("� � � <br />Billing Name � --�• , -� C � / � <br />Connection By w��.:`-- ;-�� __ <br />Phone__ 'a� ,� — � /� <br />DESCRIPTION: <br />Lot � �' - - Blo�k; i% j <br />Plat - ''/ -... /. �.,, 1/ <br />Jnpla:ted Description_. _ <br />Connection Charge(s) <br />'✓ <br />Total Fee -� �J '' <br />/ ;�' �� <br />Signed . .'c �/ �'Ss'?' '�L� —. <br />� ' customer � <br />SEESKETCH ATTACHED <br />Sewer Distr�ct <br />----� <br />Monthly Sewor Service_=�__< < _ <br />Monthly Sewer Constr. <br />Lateral <br />Abutting I.ot Line — / <br />N, S, E, W_ i��� .,- �' !, , ft. <br />Approved BY--� ~_ ; � _ , <br />City Engineer <br />i, <br />Issued By '� � ----^ -> — <br />Inspection B ` / <br />�atelnspected_/� `�� `�� <br />N0. <br />