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Li <br />City of Everett <br />Engineering Department <br />� <br />T <br />Sewer Application and Permit <br />No. <br />Service <br />21419 DATE <br />Billing Address, <br />City, State, Zip <br />Owner (Mortga <br />Billing Name_ <br />Connection By. <br />Phone <br />DESCRIPTiiJN: <br />Lot _— <br />Block <br />Division or Addition <br />Tvoe Permit: <br />SEE SKETCH ATTACHED <br />INSPECTION <br />Utility Account No <br />Connection Permit <br />Connection Fee_ <br />Total Fee <br />Signed <br />Customer <br />Sewer District <br />Monthly Sewer Service. <br />Monthly Sewer Constr. <br />Lateral <br />Abutting Lot Line <br />N, S, E, W <br />Approved By_ <br />City Engineer <br />Issued B <br />Inspection — <br />Date Inspected lV3�i�7b <br />No. 21419' <br />i <br />1 <br />