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eW <br />City of Everett <br />Engineering F. Community Services <br />Sewer Application and Permit <br />NO. 21753 DATE <br />Service Address304 'g15T. cD T�_ <br />Billing Address' <br />City, Stk.te, Zip t __ <br />Owner (Mortgagor) L <br />Billing Name ' <br />Connection By 'r-•'1 L-- <br />Address'•' <br />Phone— <br />DESCRIPTION: <br />Lot Block <br />Plat L,I- <br />Unplatted Description <br />Type Permit: IC_ v Q_J. 0^'jf—t:-7 I ..._� <br />5—zil3 <br />CHART NOM <br />a« <br />0 <br />Utility Account No. <br />Permit Fee <br />Co inection Charge(s)_ <br />� I <br />Total Fee — <br />Signed L <br />Customer <br />i <br />Sewer District - 't:' �• 1 <br />Monthly Sewer Service <br />I <br />Monthly Sewer Constr. <br />Trunk ^� <br />Lateral <br />Abutting Lot Line <br />N, S, E, W <br />i <br />Approved By f7__ <br />C¢y Engineer <br />Issued By !- L r L-4 <br />I <br />Inspection By A0Qa *� <br />)ate Inspected % <br />NO. <br />a <br />