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everett <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />NO. 20166 DATE <br />Service Address <br />Billing Address <br />City, State, Zip <br />Owner JMortgagor)___ <br />Billing Name <br />Connection <br />Address <br />Phone_ <br />DESCRIPTION: <br />Lot <br />Block_ <br />Division or Addition <br />Remarks: <br />SEE SKETCH ATTACHED <br />Utility Account No <br />Connection Permit Fee_ <br />:tom <br />Connection Fee - 7 3 <br />Total Fee <br />Signed <br />Cwlomer <br />Sewer District <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />Approved By <br />Cdy E,,ginv,n <br />Issued <br />Connection By <br />Inspection By�' �trL�►u.— <br />Date lrspected 3 �_ <br />