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evereti <br />Le <br />City of Everett <br />Sewer Application and Permit <br />No. 23254 <br />DATE <br />CHART NO. F-30-a9 -5 <br />27 <br />Service Address 6� 3 a�—r <br />J��e Utility Account No. <br />Billing Address <br />Permit Fee <br />Connection Charge(s) <br />City, State, Zip <br />Owner (Mortgagor) <br />Total Fee — <br />Billing Name <br />Connection By <br />Address <br />_ Signed Customer <br />Phone <br />DESCRIPTION: <br />Sewer District <br />Lot Block <br />Monthly Sewer Service <br />Plat <br />— <br />Unplatted Description ' <br />Monthly Sewer Constr. <br />lime Permit: <br />SEE SKETCH ATTACHED <br />INSPECTION <br />Abutting Lot Line <br />N, S, E, W <br />Approved By � <br />City Engineer <br />Issued <br />Inspection By <br />Date Inspected Q ' 4 ' 7 4 <br />No. 23254 <br />