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MUKILTEO WATER DISTRICT (
<br /> APPLICATION FOR WATER
<br /> ', � , Acct No.:�I �
<br /> .��/ _
<br /> MeterSize: ' ServiceAddress: �� �=��'" ',� ' r'
<br /> Number of Units: � n��� 3 1 y �
<br /> Meter will be used for(check all that apply): �'� Domestic Irrigation Fire Service Fire Line
<br /> t hereby apply for water service and agree to be govemed,in accordance with the resolutions,rules and reg�Iations of the MIJK�L7'EO W'ATER
<br /> DISTRIC7'(MWD)pertaining to water service,now or hereaRer in ef'fect 'fie undersigned as owner or representative of the hereimdcscribed
<br /> premises hereby agecs az follows:
<br /> (I) The consumer agrtts to insla��.operak and meintain ut all�imc',0¢ir plumbing syskm in wmpliance e'ith the arzent ediaon oC�he Uniform Plum m6
<br /> Code u it pertains to�he provrntion oftonUmination.and protection Gom lherma�expans�on duc to a closed sysicm lhat wuld aar wilh Ihe Prcsent or
<br /> fuwre installatlon of back0ow preventers on ihe consumer's s�rvice and/or at plumbing fizt�d to main�vn those backllow prcvention azsemblics in 6�d
<br /> (2) Thc consumer agees to inslall all backflow prevention asscm6lics rcquesmd by Ihc MWD,
<br /> wrorking orG:r. The assemblics shall bc of a type,six end make approved by�he MWD arid�hc Washington State Departmrnt of Heal�h Autho�iry. 'llm
<br /> azsemblies shali be installe�in nccordana wilh all standards utablished by�he MWD.
<br /> (3) The wak:meler will not be installed unlil a waler use survry haz becn submitled 6y U:c app�icant and ihe DisVicls Cross ConnaOon Coniro�Specialisl ha5
<br /> determi�md if ihe cuslomer wiil need to inslail a backflow pmventer on Ihe cusromer's side af the meter.
<br /> (J) That 9u wst o(any extension of ihe wa�cr service,rznewal,replacement or repair to mach end scrve the propeny described shall be bome by myself or
<br /> assi;ns as awnu(s)of the prcmiscs.
<br /> (5) That all pipes,water�meazuring devices and uther wnnection equipment upstroam Gom the meter shall,¢Iter Ihcir in4allalion,be end becnme Ihe property o
<br /> �he M11WD,subjttt lo all i6 rcguletions pertaining to watcr scrvice.
<br /> (6) That atler installation,if ineter or meter box and nppurt:nmces are buried nr damaged,the oxner,wiil be held raponsible and charged for same.
<br /> (7) 77iat the MWD,its otlirsrs and agenls,shail have the right of ingress and egress Io go upon the premisa end property ducribed hercin for ihe putpose oC
<br /> inspectiun,connecting or disconnecting the sen•ice or for such other pumoses os Iho scrvice may¢quire. It is also understood dunng Ihe time that any of
<br /> the w�akr mains may be oul of service by rcason of nny omergency or impmvemen6 aulhoriud by Ihe MWD,in any sVect or olher iocation in which lhcy
<br /> may havc becn laid,thc MWD wi��not bc rcqwrcd lo(umish wamr Juring tlic pro@ress o(such improvcmcnts lo ony wnsumcr whose supply may thus bc
<br /> cut oR,or be liable for any damnga(or i�s failure to do so.
<br /> (a) n ate(s)m reg st rlthe xa crcconsumcA. 'Ihe A1WD shal not be hcld Gablc for'damn6e by walerdorolher causc resulling fromsdefectivenplumti n�orh�
<br /> "applianecs insinlled by Ihe owner or occupant on Ihe prcmises supplics wiW aater,and il�e(act lhat agents of ihe MW D may have inspected ihe piumbing
<br /> nnd applianees shall not be plead as n basis(or recovery in cace ofdamage i4 hforeshid. if 1he supply of water shail Cnil or be inlertupled by t�son of
<br /> acciden4 low prcssurc or o�hcr cause w�haBavcr,Ihc MWD shall not M1c hcld liable for damages nor shell such(ailum or intcrtuption for my rcuonable timc
<br /> be hetd to2on"stitute e brcach of wnuact on the part ofllu MWD or in nny a'ay relieve Ihe wnsumer,whclher tenan[or ownbr,!rom p:r(omiing Ihe
<br /> obligation of such tenwiCs or oxner's wnvact. Watcr shall bc uscd by applicantonly on the prcmiscs dcsaibed hcrein. A ncw applicafion shall bc filcd
<br /> should water be dcsired for othcr premisa although IocataJ on land ducribcd hali au[acknowledFes information ae lo the recommendatian and
<br /> (9) '1'het the 117WD recommends InstalluNon of a pressure reguiatlng vahx• APP�
<br /> euumcs full roponsibllity for inetelling ar faiting to Ins�all a prusurc regulaling valve on Iht water syslnu[o pro�ttl it from high
<br /> preffure:.� :__�� INT.
<br /> (10) The M1iH'D uliliue check valvee a[the meler lo prevcot water rch�rning lo Ihe Dislricu m 9lnf.p�wledga ioformalion as�ro�ihe recommenJatim�
<br /> e:pamian tank�lo prevent eucssive preexurc build-up causeJ by IGe wntcr hnlcr. ApP' . �
<br /> and aeaumea full rnponaibility for immll(ng or faiiing to install a thcrmal eap�nsioo lank.-���NT•
<br /> �, i f ,; I 'I' OLOCK: —
<br /> SGRVICG ADDRESS: ����"�/� � � �� ' '' LOT NO.: � — , _
<br /> � • '' PLAT4MIG: i��'��;�� �"/�,;
<br /> CITY/STATF/ZIP: • , J/���
<br /> OWNER'SNAMG: � �
<br /> � r/� c�r:. ��'�:'7� �j��yi!�'�-� ' LBGALDCSCRIPTION
<br /> ;r(�:�.� �,;i i jt ��1� .>i
<br /> OWN�R'SADDRESS: `� �i., '��;� !%'t'J.'.�� �.L
<br /> ��7,r,'� ^r�i �_,r",i.,, DLDGPGRMITISSUGDDY: /
<br /> CITY/STATC2IP: y
<br /> ltic prcmises are to be used as a J MPORMATION LETTER GIVEN:
<br /> $f:RV('E'!�E: �F�' ?:i,�";�,- �
<br /> i- (qScrviceinsmllntion&wnnectioncharge S �.�"�j �'�_J:;
<br /> Developerinsmlled: s _,�.i�'��.1�
<br /> Disuict Insulled: (2)Gencral Facili�ies conneaion chargc
<br /> (3)Othcr s
<br /> UistrictlnstallcJfuture: s -���- ,�����
<br /> To�al amount rc:ciecd with applicacion
<br /> IT IS UNDBRSTOOD Ihat Ih�s Application,allhough signed,ehoil not be binding u�wn the b1UKILTEO WA'fER DIS7RICT u��pprovc�'��r jS'iRICT.
<br /> I�cation for installetion of a inc i eter water supply
<br /> i,tNe undcrsignad,oener(or rcprcsrnta�ive)of ihe property described nbo�•e,do hcreby mnke app�
<br /> servi�tronnec)ion,includingappurtenance�endellnetessary.(nyof,almyezp:nscs. Q�Ir��l' ' �) �����)
<br /> Da�cdthis `� dayof ' � - � �
<br /> �� � �` ��
<br /> MPLICANTS'SIGNATURE. �'�� �� �YIUNII..TE� � �' "�. "
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<br /> ppplicanPs Nwne(picasc prinQ. � '�"� ;I� �. i i 1/ ,,/.;! "FI �'J 7 /i,, � � . .
<br /> IwanPsAddrcss&PhoneNumber. ���� ? ���'�� � f L~J /I � } �
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<br /> CROSS CONNECTION CONTftOL SUMMARY ASSESSMLTIT�ACKFLOW REQCIRE��"�S � p��G f�D 0%
<br /> Type of Device: Size of Device: i
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<br /> APPROVEOi�'�^ �fUKILTEO�VATERDISTRICC _- .
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