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everett <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />NO.20434 DATE <br />ServiceAddress <br />Billing Address.-.f�/c' ; • r <br />City, State, Zip, - <br />Owner (Mortgagor) <br />Billing <br />Connection <br />Address ` <br />Phone_ <br />r. <br />DESCRIPTION: <br />Lot <br />Block_ <br />Division or Addition--`r : r,:1Lt_'t <br />Remarks: <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />as <br />Connection Permit Fee__ <br />Connection Fee &/ <br />Total Feer- <br />.y <br />Signed ` _�' <br />Cnwwm r <br />INSPECTION <br />Sewer District-'11 <br />Monthly Sewer Service <br />Monthly Sewer Constr._ y <br />Approved By. _ — City � / : �1) <br />Enpmaer <br />ssued By <br />Connection By _ <br />Inspection By-, fp ' o <br />)ate Inspected /' f1&73 <br />