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i � evcrett <br />City oi Everett ;a - - <br />Sewer �4►ppli�ation and Permit <br />. t �����a= <br />NO. Z����194 DATE ua,,,ax,s-�c,-��ea-- <br />Service Address �i;���Z-�r---- <br />Billing Address — - <br />City, State, Zip ���t��S �ll?� <br />Owner ���+�-�, <br />Connection by _��tr_,y�� _ <br />Address 7gg�_i�t�„�, -- <br />. . <br />. <br />Legal Description: <br />Lot _ <br />Block <br />Plat <br />Unplatted Description: <br />Type ot Permit Nev conneatim __ <br />Remarks <br />IMPORTANT! <br />CALL 1-B00-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-6810 FOR INSPEG fION <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />Permi;Fee $ <br />Connection Gharge <br />Trunk <br />Lateral <br />CHART N0. <br />_, � � <br />';•ti7 /). C `i na� <br />' ,��1 <br />$ <br />Tolal Connection Charge $ �30.00 <br />Utility Development Fee <br />Wa1er <br />Sewer <br />Total Development Fee <br />$ <br />5ewer Bond District non � TTT <br />Abutting Lot Line <br />N, S, E, W _ <br />Approved By _ <br />Issued By <br />Customer Signature <br />�� , <br />Incpec�ion By��¢,�.� <br />Date Inspected ��f •���'�' <br />No.28039 <br />n. <br />i <br />I <br />