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everett <br />,e <br />City of Everett <br />Sewer Application and Permit <br />NO. 25768 DATE _ -kil; 91,1QRF <br />CHART <br />.5,ru7- ib eftiar"/& /L/10/911 <br />Service Address_ *"jam Se tility Account No. ---- <br />Billing Address _ Permit Fee — <br />City, State, Zip — <br />Owner (Mortgagor)_.fy,�ntn � -- <br />Billing Name_ - <br />Connection By - <br />Phone IST----- <br />DESCRIPI ION: <br />Lot Block <br />Plat mt—Yt <br />Unplatted Description <br />Type Permit: <br />_`1Cw, =nnectiDtL------ <br />Remarks: <br />IMPORTANTI <br />CALL 1-80OA24 5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8811 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Connection Charge(s) - <br />Total Fee /2 V kt <br />Special t1t111ty Fee Ord 1171-85 <br />water 11194 60 <br />Sewer WIN l�I.aD <br />gam l33mo <br />Signed <br />Customer <br />Sewer District_ _ovn -4 <br />Monthly Sewer <br />Monthly Sewer Constr. <br />Trunk <br />Lateral <br />Abutting Lot Line <br />N, S, E, IN <br />Approved By <br />---M C veer <br />Issued By <br />Inspection By <br />Date Inspected c <br />No. 25768 <br />INSPECTION <br />