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everett <br />7 <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />NO. Z0 e 8 4 DATE <br />Service Address I r _ - -- _ ___ - —_ _ <br />Billing Address__— <br />City, State, Zip—_- <br />Utility Account No. <br />Connection Permit Fee <br />Connection <br />Owner (Mortgagor) Total Fee <br />Billing Name <br />Connection By — <br />Address r •1 Signed - — <br />Customer <br />Phone- , <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />Sewer District <br />Remarks: ` " <br />'r <br />J <br />SEE SKETCH ATTACHED <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />Approved By 1 <br />City Engineer <br />Issued By <br />Connection B <br />Inspection By U / <br />Date Inspected 31,A 3 <br />