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evcrcd <br />City of Everett <br />Engineering & Community Services <br />Sewer Application and Permit <br />NO. 2 21.9 DATE <br />Service Address <br />Billing Address �C • '-Jr"� <br />City, State, Zip,."•' /, h ��-- %l <br />Owner (Mortgagor) �-- — <br />Billing Name <br />Connection <br />Address <br />Phone_ <br />DESCRIP ION: <br />LotBlock_ <br />Plat — <br />Unplatted Description <br />Type Permit: <br />Remarks: <br />i <br />0 <br />SEE SKETCH ATTACHED <br />CHART NO.�'� <br />�000r TL�o <br />Utility Account No. }' + 3 2—"'f — <br />'J <br />Permit Fee_ Jy <br />sue' <br />Connection Charge(s) <br />Total Fee_ <br />Signed <br />Cnrtomer <br />Sewer Districts '_ -= j <br />Monthly Sewer Service -- <br />Monthly Sewer Constr. <br />Trunk _ <br />Lateral <br />Abutting Lot Line <br />N, S, E, W <br />Approved By X <br />Cny Eepmeer <br />Issued By —14 <br />Inspection By <br />Date Inspected_ l y 7•� <br />NO. _ <br />