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everett <br />City of Everett <br />Engineering Department <br />Sewer Application end Permit <br />NO. 2-019 <br />DAI I <br />Service Address _ <br />Billing Address — <br />City, State, Zip <br />Owner (Mortgagor) <br />Billing Name _ <br />Connection By—T_—_-_-__- <br />Utility Account No.-__ - __ _ <br />Connection Permit Fee—__ <br />Can action Fee <br />Total Fee <br />Signed_ <br />Customer <br />Phone-_ <br />DESCRtPTION- <br />Lot ._— <br />Block_—._ _ <br />Division or Addition <br />------Sewer District <br />-- - -- - ---- Monthly Sewer Service - <br />Remarks: <br />Monthly Sewer Constr.- <br />Approved By er I ,I <br />nv nginen <br />Issued <br />Connection By <br />Inspection By <br />Date Inspected <br />SEE SKETCH ATTACHED <br />