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everetl <br />i6e <br />City of Everett <br />Engineering & Community Services <br />Sewer Application and Permit <br />NO. 2 % 1 5 6 DATE �1— <br />Service Address ''� �' % t. <br />Billing Address <br />City, State, Zip! <br />Owner (Mortgagor) <br />Billing Name <br />Connection By— <br />Address— <br />Phone— <br />�/ <br />5 3 - � 7!T <br />DESCRIPTION: <br />Lot <br />Plat <br />Unplatted Descriptioi <br />Type Permit: <br />Remarks: <br />CHART NO.121fI7-8-6_ <br />Utility Account No._ <br />Permit Fee <br />( <br />Connection Charge(s) ` <br />Total Fee <br />l , <br />-'_4c, , <br />Signed <br />Customer _ <br />Sewer District LLT_ <br />Block — Monthly Sewer Service <br />Monthly Sewer Constr. <br />Trunk-4- <br />Lateral <br />Abutting Lot Line <br />N, S, E, W <br />- - — ---- Approved By <br />City Enpmeer <br />- Issued By <br />a <br />SEE SKETCH ATTACHED <br />i <br />Inspection By 4 a,, <br />Date Inspected <br />NO. i <br />i <br />