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everett <br />e <br />City of Everett <br />Engineering Department <br />Sewer Application and Perrriit <br />PIO. �� � . . DATE __ <br />Service Address -- <br />Billing Address <br />City, State, Zip <br />Owner (Mortgagor) ' <br />Billing Name <br />Connection By — <br />Address <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 Cusmmer <br />Sewer District <br />Monthly Sewer Service. <br />Monthly Sewer Constr. <br />SEE SKE"iCH ATTACHED <br />4butting Lat Line <br />N, S, E, W <br />Approved DY City Engineer <br />Issued <br />Inspection 8y�i�'i��� ' ��' <br />Date I nspected �/Z/ 7 7 <br />N0. <br />ft. <br />