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<br /> ' MUKILTEO WATER DISTR[CT �
<br /> APPLiCATION FOR WATER
<br /> ;?i�. �,i:r:i' ; i�I�'",i ; ;i, Acet.No.:�_��.3
<br /> Metcr Sizc: Service Address:_-� � ' � �Q a 3 l L! � (
<br /> Number of Units: /
<br /> Meter will be used for(check all that apply): Domestic Irrigation Fire Service Fire Line
<br /> I hereby apply for�vater service and agrce to be govemed,in accordance wilh the resolutions,rules and regulations of the MUK1L7'EO WATHR
<br /> DISTRICT(MWD)�crtain;ng to walcr servicc,now on c�rea�cr in ef(ect. 'Ihe undcrsigned as owncr or representative of thc hcrcimdescribed
<br /> premises hereby ayces as follows:
<br /> (I) Tbe consumer ag¢es ta install,opemle and maintain at all times,�heir plumbing system in cornpliance wilh Ihe cwicnt eJitian of Ihe Uniform Plumbiri�
<br /> Code as il petlains to Ihe prevenlion of conta�ninalion,and protection Gom thertnal expansion due lo a cloted syslem that cauid ocar with the pmsent or
<br /> fulum ins�allation of back0ow prcvcnlcrs on thc conmmci s scn'icc;mNor at plumbing fixtures. -
<br /> (2) ��•The consumer agr[es to inslall all bacAflow prevenlion assemblics requesled by the MWD,and�o maintain those 6ackilow prcvention assemblies in guod
<br /> ��ro�king ordec The azsambiies snall be of a type,size and maF:c approved by�he MWD and Ihe Washinglon Stale Deparunr.nt of Health Anthority. Thc
<br /> asscmblics sliall bc installcJ in accordancc wi�h nll standards cstablishcd by:hc MH'D.
<br /> (3) Thc watcr meler will not bc installcJ until a watcr usc survey hac bccn su6mittcd by Ihc applicanl and Ihc Districls Cmss Conncction ConUol Spccialist liis
<br /> delemiineJ if ihe custamer will nccd to inslnll a backilow preventer en Ihe astome�'s siJe of the meter.
<br /> (4) 'flml Ihe msl o(:my cxtcnsion uf tlm walcr scrvicc,rencwal,rcpinccmcn[or rcpaii lo rcach v�J servc Ihe properry dcscribed shall bc 6omc by mysel(ar
<br /> assigns az owncr(s)of�hc premiscs.
<br /> (5) 'l6ut all pipes,waler mcaturin6 Jevices and olher ronncetiun cyuipment upstream fwm lhe meter shall,n�er iheir insmllation,be anJ become Ihe propetly��
<br /> thc A1WD,suhjttt lo all iLc rcgulalions pcnaining ta watcr scrvicc.
<br /> (6) 'I'hat a(tcr inslnllation,iFmcicr or mctcr box and appurtcnanccs nrc buricd or damagcd,the mcncr,will bc hclJ responsiblc anJ chargcd for samc.
<br /> (7) That thc MWD,iLs olliccrs end agcnts,shall havc the righl o(ingress and cgress to go upon Ihc prcmiscs and nroperty dcscribcd hcrcin for tl�c purposc o!
<br /> inspcction,connccling ar disconnccting Ihc scn�icc or for such olhcr purposcs as Ihc scrvicc may rcquirc. It is also understood during Ihc[imc Ihat any of
<br /> �Im walcr mains may be oul of scrvice hy re:�son of any cmer6cncy or impwvcmenLt authori�cd by Ihc MWD,in a�y streel or olher location in which ihcy
<br /> may havc bccn laid,thc M WD will not bc requircd la fumish watcr Juring 1hc pwgress o(such improvcmcNs lo any wnsumcr whosc supply may Ihus be
<br /> cut o(T,or bc liablc for any Jamagcs for iis failurc lo do so.
<br /> (8) That Ihc MWD shall havc thc�ight m chan6c tlu ralcs at any lime by Resolutian,m�cmporarily discon�inuc ihc scrvicc lo consumcrs,and lo inslall tlic
<br /> mctcr(s)to rcgistcr lhc watu wnsumcd Thc M\VD shall not bc hdd Iiablc for damagc by walcr or othcr causc resulting Crom dcfcclivc plumbin6 or
<br /> nppli;mccs inslallcd M1y thc o�mcr or occupant an Ihc prcmiscs supplics�vilh watcr,anJ tltc fnct that�gcna o(Ihc M WD may have inspccicd Ihc plumbing
<br /> anJ zpplianca shall not bc p�cad as a basis(or recovcry in case oCdamagc at aforesaid if thc supply o<<+'��cr shall Tail or bc intcrtuptcd by rcawn o(
<br /> a:cidcn4��oiv ptessurc or olhcr causc whalsun�cr,lhc�1ND shall nol bc hclµain e�cJc I c c nsumcrs1Nhclhchlcnlanl m owner,�l om pDdumi i�6s�'oablc timc
<br /> bchcW�tocunsuNlcabrcachu(coNmclonlhcpartofWcMWD'orinru�y� � �y �_-
<br /> abligatian of such tcnanCs m owncr's contracL Walcr shall bc uscd hy applicant anly on lhc prcmiscs describcd hcrcin. A ncw applicution shall bc Glcd
<br /> shuWd w�rtcr lic Jcsucd fur olhcr prcmiscs allhough laatcd un IanJ dcscribcJ hcrcin. '�-. ��
<br /> (9) '1'6at�hc N�VD remmmcnJs insleilalion of a pressurt rcgulating��ah'c App���anf acknowteJges informa�ion as lo t6e rerommcnJnliun:md
<br /> assumcs full rCsponsihiiity for inslallin�or failing tu inslall n pressurc reFula�ing valvc on ihe waler syslem lo prolec�it frum high
<br /> pressure:�` �=/i IN'1'.
<br /> (10) Thc INWD ulilixes check vnlves at�he mc�cr�n prcvcnUva�er retnrnin�lo Ihc Districls muins. "�he 111WD rttmnmends instulle�ion af a�hermfl
<br /> expansinn lank lo prevcnt exttssi�'c pressnre build-up taused by Ihe a'a�cr he�ler. App�icant acijnn»iedges informa�ion as�o thc rccommcndation
<br /> nnJ assumcs full rzsponsibility for installing ur fniling lo inslnll a Ihcrmal cxpansion tank. ����� INT.
<br /> ���,I i� � ���i� � �i '' �' I,O'PNQ /.� ULOCK —
<br /> SIiRVICGADDRISS � � �. - :� i,�;�;'� � / ' � _�'
<br /> Cfl'Y/STATPJ"LIP: � � ' PLA7'NAML•. %� '���� �
<br /> � �ii `,��. ..�:i"I('� /�I��/T'�''�''. LGGAI.U85CRIPTION ���� .
<br /> ORRJGR'SNAMG: . � '
<br /> ONNF'.R'SAUDRL'SS:,'J<i/�!Jj' ��'„i,(% r� �� — .�.y��„y!
<br /> t,r.�. r
<br /> CI'I'Y/STAT[1lIP: ' ' - ��=�'''3 _ l3LDG PLRMI'P ISSUED UY: ` -
<br /> Thcpremiscs:vctobcuscdua'�, �'��� INPORMA7'IONLGTTERGIVC;N: —..---
<br /> SfRVIC6TYPF.: CIIARG�S' � `:��'%�' ,
<br /> i� (I)Scrvicc instalinlion R conncction char6c 5 —
<br /> Ucvclaperinslallcd: s :��:;13• �,'. '
<br /> Uistricl Inslallcd: (2)Grncral facililies conntttion cha�gc —
<br /> District inslallcd�Wu�c (3)Othcr S ���^T
<br /> Tami nmount mccivcd wi�h npplica�ion S
<br /> IT IS UNDCRSTOOD tlmt this Applicalion,alWaugh signcd,shall not bc binding upon�he MUKILTGO WAT[R DISTRICT until appmvcd by�hc DlSllt;C�I'.
<br /> a/!/ t)11 i �_}
<br /> 1,thc undcrsigncd,o��mcr(or rcp¢sentativt)of lhc property Jcscri6cd abovc,du hcreby mal:c application(or installation o(a -ineh diamcicr watcr supply
<br /> scrvicc conncction,including oppuncpaqccs,and all ncccssa�lalmr at my czpcnscs. ���I'�i i '" �� � ��
<br /> Dalcd this �'' Jay of -� ' ' .. ..
<br /> � I ^_.�,.
<br /> �� ✓ i��i
<br /> AI'PLICANTS'SIGNATURG: �'A -I� • i _.��. � �
<br /> Applic:mt's Namc(Plcasc prinl): ��, �� � ,f U��I l�f !N � � � �Z ���, � . ' � ,
<br /> _ ,.� yf=, ,� � . � L ,' J{i� � i� l.• N i
<br /> Applicant'sAddress@PhoncNumba '� � ,_, � ,�
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<br /> CROSS CONN[CTION CONTROL SUMMARY ASSESSM[NT BACK�LOW RBQUIRHD? :"\YF�+ p�� �6 �
<br /> SiuotDevico: CCSlnitials �
<br /> Typc o(Dcvicc: . Z�
<br /> API'ROVED'd/:�}�1UKILTF,ONATERDISTRICI' � � /
<br /> ,,:.i, �� f /x>%?ct�7 i,����d iar._
<br /> , i Datc:�
<br /> I3y:_�� .,: . - -�-- ---
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