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, inWING G� <br />g S888R8,'d 13 8g <br />a M <br />Sewer Applicatio anc. P , . it <br />µ <br />T2Af/ 3 <br />29569 DATE <br />109 69th St SE <br />Service Address <br />Billing Address 541b 140th P1 SE <br />City, State, Zip Everett WA 98208 <br />Owner" linana <br />Connection by — <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Block — <br />Plat <br />Unplatted Description: <br />Type of Permit Now -annecelan <br />Remarks <br />IMPORTANTI <br />CALL 1-800-424.5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />CHART NO. <br />Permit Fee $ 7A-00 <br />Connection Charge <br />Trunk $ <br />Lateral $ <br />Total Connection Charge $ <br />Utility Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W — <br />Approved By <br />Issued By <br />Customer Signature <br />-0- <br />$ 175.00 <br />$ 471.00 <br />$ 650.00 <br />Rh <br />Inspection By <br />�y <br />Date Inspected <br />INSPECTION <br />29569 <br />1W <br />ff. <br />