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everett <br />e <br />c�cy ot e�erett <br />Engi�eering g Community Services <br />Sewer Application and Permit <br />NO. '' ��� :1 / ; i DATE i � ��%ir <br />Service Address_ `f� � ��% '� � _.- ' • .� � � <br />BillingAddress ��%� `� y'� `� _ � -/J • <br />CitY, State, 2ip � % ' ,� .//r • �r'Q�� <br />� , i <br />Owner (Mortyagor)_�_� <br />Billing Name <br />Connection <br />Phone �%� . ,' - /'=/ <br />7 <br />CHART N0. �J/�- 7_ R- S <br />;i <br />� S ;—�� ,� a, <br />3-�5-�5 .�'. <br />/ 'W <br />Utility Account No. �" �' �- i 77 -°U <br />-, oj <br />Permit Fee ../V <br />' O °i <br />Connection Charge' �) = <br />u� <br />Total Fee i J � <br />Signed,_ � . 7 / <br />^.ustomer <br />DESCFIPTION: Sewer U�strict� � _ - f �- <br />Lot ^�� Block J <br />Pl�t • ! — Monthly Sewer Service .:i'. r0 <br />Unplatted Description Monthly Sewer Constr. <br />Type Permit: � <br />Y � <br />SEE SKFTCH ATTACHED <br />� <br />_ >v = . . � <br />Abutting Lot Line <br />N, S, E, W <br />�, <br />Approved By� � -�l . <br />Gry Enpmen <br />Issued By - _ <br />Inspection B � ...� <br />�ate I nspected�a ` ,���_ <br />NO. <br />�� � <br />