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ri <br />City of Everett <br />Engineering Department <br />Sewer Application and Permit <br />NO. r. 1 b f t l DATE <br />Service Address C1 l l7 q --5 R:D S <br />Billing Address <br />City, State, Zip <br />Owner (Mortgagor) <br />Billing Name <br />Connection By <br />Address <br />DESCRIPTION: <br />Lot <br />Block <br />Division or AdditionAA -r 14 1= 1 A.L <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />Connection Permit I <br />Connection Fee_ <br />Total Fee__ <br />Signed _ <br />Customer <br />Sewer District <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />Trunk <br />Latetal <br />Abutting Lot Line <br />N, S, E, W <br />Approved By <br />City Engmem <br />Issued <br />Inspection By <br />)ate Inspected._ 3Z' 7 7 <br />NO. 21.667 <br />