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CHART NO. <br />everett <br />Le <br />City of Everett <br />Sewer Application and Permit <br />No. 23159 OATL <br />Service Address_ <br />Eillinq Address_._ <br />City, State, Zip_ <br />Owner (Mortgagort_ <br />Billing Name <br />Connection By_ <br />Address __ <br />Phone_ <br />DESCRIPTION: <br />Lot Block_ <br />Plat __ <br />Unplatted Description —_ <br />Type Permit: 1, <br />Remarks: <br />SEE SKETCH ATTACHED <br />Utility Account No.___ <br />Permit Fee <br />Connection Charge(s)— <br />Total Fee <br />Signed <br />customer <br />Sewer District <br />Monthly Sewer Service_ _ <br />Monthly Sewer Constr. <br />Trunk <br />Lateral <br />Abutting Lot Line <br />N, S, E, W <br />Approved By ' ' <br />c1n Engineer <br />Issued By <br />Inspection By <br />Date Inspected (9 <br />NO. 23159 <br />INSPECTION <br />