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everett <br />� <br />City of Everett <br />Engineering Depanment <br />5e�nrer �►p��accat9or� and P'��rn��� <br />N0. <br />DA'fE <br />Service Address �"�y�-% 1 1–�—�'--�E � <br />Billiny Address_----- ---- <br />City, State, 7_ip <br />pwner (Mortgagor) -- <br />Billing Name_. ------ <br />Connection By – <br />DESCRiPTION: <br />Lot __._--- <br />Block_ <br />Division or Addition <br />-r...... oa...,i.• <br />Remarks: <br />SEE SICETCH AT?ACHED <br />; <br />Utility Account No._. <br />Connectian Permit Fee <br />Connection Fee <br />Total Fee <br />Signed Customer <br />Sewer Dlstnc1 <br />Monthly Sewer Service. <br />Monthly Sewer Constr. <br />Trunk <br />Lateral_ <br />I Abutting Lot Line <br />N, S, E, W— <br />Approved ey Ciry Engineer <br />Issued <br />_ •� <br />Inspection By �`S A"L�1' Y o �• N4 �� <br />Datelnspected 3/��/�' <br />„., r,.. <br />NO. ' <br />