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everett <br />� <br />Clty of Everett `_ - - . - - - • <br />; : -.._ _ : _ <br />Sewer Appl�icatiQn �'and Permit <br />' _ - � z'S,� � - - - <br />� .T <br />N0. 2,� � .�► g y ''} _ .DATE _ .. M....1. ,_?-riv9i <br />Serv(ce Address _— <br />BIIIIng Address —gp--�-�,�— <br />City, State, Zip <br />Owner I . <br />Connectlon by <br />Address <br />Phone __ <br />Legel Descriptlon: <br />Lot <br />Block <br />Plat ..,..--'--� <br />Unplatted Descrlptlon: <br />Type ot Perm(t <br />Remarks <br />IMPORTANTI <br />CALL 1-B00-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACFIED <br />CHARi� NO. <br />S�e�� Iz �>�S���y <br />� -,/- �f� <br />Utility Account No. --- <br />Permit Fee $ _�� <br />Connection Charge <br />Trunk <br />Lateral <br />Total Connection Charge <br />Ulility Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />$ <br />$ <br />$ <br />$ uq ��_ <br />$ <br />$ —�'�O�pD-- <br />Sawer Bond District g���,��}!��— <br />Abutting Lot Llne <br />N, S, E, W _ (t. <br />Approved By <br />Issued By _— <br />Customer Slgnature <br />Inspection By < <br />Date Inspected <br />i,.� ;i��_i,�i i�;. � <br />,y�� �_. <br />7_ f•_ %i <br />No. 28159 <br />