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everett <br />City of Everett <br />Sewer Application and Permit <br />No. 28150 DATE _ u�,Y,. �, �n� <br />Seiv(ce Address �3 -�stlis� 4Y Utility Account No <br />Billing Address <br />City, State, Llp <br />Owner au�assiln nw <br />Connection by p�� <br />Address <br />PhOf1B 33� r,�g}� <br />Legal Description: <br />Lol 35 --- <br />Block <br />Plat AiQae� Lno <br />Unplatted Description: <br />Type of Permil ywv caen�ctien <br />Remarks <br />INlPORTANTI <br />CALL 1-800-424-5555 46-HOURS <br />PRIOR TO DIGGING <br />CALL 259��8810 FOR INSPECTION <br />SEE SKETCH A7TACHED <br />CHART IJO. <br />S e .��f � � °-� �' 1`1 <br />7 -I/-yl <br />Permit Fee $ ��.. <br />Connection Charge <br />Trunk $ <br />Laterel $ <br />Total Connection Charge $ <br />Utility Devetopment Fee <br />Waler $ <br />U�. fi"'f i:',I N I;�Jluil�`.,�:��i i',� <br />Sewer $. a��-00 <br />iIf4N1'�,.� ,'G50.00 <br />Total Development Fee I a.l a�$ .,.. <br />I'I l:i, i��'�.Ilfl <br />Id).H 4"fl,fpl <br />Sewer eond District I�` x���+) �'' •' �� <br />IN�'�1M,' t"I�.i{i <br />Abutting Lot I.Ine !htte1.^t3t',G <br />;f UU ? :�I.irl <br />N, S, E, W �1:;i- ,te;�1,,y� ft. <br />tU.+�q:M171',i9 <br />Approved By µ�r�y-:{F3.hp <br />Issued By .1J4=(.�l; FI ;9:.' I . <br />�, <br />�- <br />Customer Slgnature ` <br />f -..: .c <br />� �\ <br />i <br />Inspectlon By � f� `— — <br />Daie Inspected � � �� %' � <br />u,i",i��. c��ior� <br />NO. ?��an <br />