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everett <br />e <br />City of Everett <br />Engineering Department <br />/ � � � G� ,I%�,Tlz D <br />�� <br />Sewer Application and Permit <br />N0. �'� � i � DATE <br />Service Address_ <br />Billing Address__ <br />City. State, Zip_ <br />Ovmer (Mortgagor)_ <br />Biliing Name <br />Connection Bv— <br />Utility Account No.. <br />�onnection Permit F <br />Connection Fee_ <br />Total Fee <br />S <br />DESCRIPTION: <br />Lot _ <br />Block <br />Division or Addition <br />Sewer Distrct . ' <br />Monthly Sewer Service_ _ <br />Monthly Sewer Constr._ . ' �' <br />J <br />SEESKETCH ATTACHED <br />I��ISPEC?I�)i�! <br />Approved By <br />City Bigineer <br />Issued Bv <br />Connection By <br />Inspection By_1,1� �T-/��u�-�- — <br />Date I nsoected `��' �� 7 3 <br />