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1� S <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />No. 20975 <br />Service Address <br />Billing Address. <br />City, State, Zip — <br />Owner (Mortgagor)_ <br />Billing Name <br />Connection By_ <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />Type Permit: <br />DATE <br />SEE SKETCH ATTACHED <br />I': 111f I I ll IF! <br />Utility Account No. <br />Connection Permit I <br />Connection Fee_ <br />Total Fee <br />Signed <br />Customer <br />Sewet District`_ <br />Monthly Sewer;�ervice <br />Monthly Sewer Constr. <br />Trunk__ <br />Lateran_ <br />Abutting Lot Line <br />N, S, E, W, <br />Approved By <br />Cny Engineer <br />Issued <br />Inspection By �• ��0 55 P C, & d <br />)ate Inspected G- Z—G - 7S <br />NO. t; lW,) % <br />