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everett <br />.� <br />� <br />_ 4 iu 'i �c 'n� �. L G : <br />City ot Everett.: _ - ' ' - - <br />=T,.":- ' .-- <br />SewE�r Ap�licatiQn�and Permit <br />�, __ - _-�- - <br />---_::�:-z;_ <br />�� �- = =�- =� <br />N0. � $1��`� � � DAT@`� --t�nrch_�s � iyyi <br />Service Address <br />Billing Address <br />P.O, i�ox 5309 <br />Ciry, State, Zip <br />9� <br />Owner <br />ar v <br />Connection by <br />Address — <br />Phone _ <br />Legal Description: <br />Lot <br />Ulility Account No. <br />CHART N0. <br />5t n �- fa ��osf,r.� <br />7-�(-�1 <br />Permit Fee $ <br />—�b3� <br />Connection Charge <br />Trunk <br />:� <br />Lateral $ <br />Total C �nnection Charge $ <br />Utility Development Fee <br />Watar <br />Sewer <br />Block Totai Development Fee $ <br />Plat • <br />Unplatted DescripNon: _ Sewer Bond Disirict <br />_ Abutting Lct Line <br />_ N, S, E, W _ <br />Type o( Permit _ <br />v nnoc on <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 />Approved By <br />Issued By p,���� <br />Customer 8ignature — <br />ft. <br />�j� / <br />Inspection By ��t� ���— ' _ <br />Date Inspected � -' ' � <br />!�a5f'!.CTIOtJ <br />No. 2816C <br />