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City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />NO. T.0.1 <br />DATE <br />Service Address___ <br />Billinq Address_ <br />City, State, Zip <br />Owner (Mortgagor) -- <br />Billing Name <br />Connection <br />Phone_ <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addition <br />Remarks: <br />m <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />_ Connection Permit Foe <br />Connection Fee <br />Total Fee <br />Signed <br />Cmlomar <br />Sewer District <br />Monthly Sewer Service <br />Monthly Sewer Constr <br />Approved By �) <br />Cny Engmeer <br />Issued <br />Cunnecliun Cy — <br />Inspection Ry ��xu —' <br />v <br />Date Inspected-=� <br />