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<br /> • t MUKILTEO WATER DISTRICT C
<br /> APPLiCATION FOR NATER _
<br /> ! < <�1 ��>>�-I I I�::,I � lJ i J( Acct No.:�_L'1�'7 '
<br /> Metcr Size: + �'� Service Address: �
<br /> � n�oa.3 � ,��
<br /> Numbcr of Uni[s:.—_T � Uomes!ic Irrigation Pire Service Firc L�ne
<br /> � Meter will be used for(check all that apply):
<br /> UISTRICT(M WD)pchi n'g to t�t rrsen i ce,now orcherea(ter in e(fecL,Tluhunde�igned asUowncr or represcntauvehofM e her Tn-descri�'c'd t
<br /> prcmiscs hereby agrces as fullows:
<br /> (I� Codc az5it pctla ns to�he prevcm un o(conCuninalion,`aud'protccfonrGom Ihcrm I enp�nsion Ju'c toca ciosed systcm that could occ�un�illh�p�cs�nt���r
<br /> (uWre installalion o(back�ow prwenlers on Ihc consumer's scrvice andlor at p�umbin6 GxWres.
<br /> �Z� Tor6ing o dcr.aThc assemblics shall bc,of n type siu and make appmvcd by the h1WD and Iha Nashington State Depanmc t olHeal�h Authority Th a
<br /> azsemblics shall bc inslallcd in ncmrdancc witli all stmidarJs cstablishcJ 6y thc hiWU.
<br /> (3) The water meter will not be insmllcd until a water we survcy has been submitted hy thc applicanl md Ihe DistricLs Cmss Conneqicn Control Specialist has
<br /> Jetermined if ihe customer w'ilI nced to install a bncAOo�v preeenier on 0¢customer's side uf the me�er.
<br /> (.<? 'fhat thc cost o(vry cxtcnsian u(dic wat<r scrv��c,rcnnral,rcplaccmcnl nr rcpair�o reach and scn'c thc p�opcny dcscribed shall bc bomc by mysdf or
<br /> :�signs as owncr(s)a(thc prcmiscs.
<br /> (5) Tha�ali pipes,water measuring Jeviws and other connection equipmrnt upstrcam Gom tiie mekr shall,aRer�heir ins'allatiun,be anJ become tlm propeny�>�
<br /> Ihc A1WD,subjcct�o all ils�eEulalions pertaining lo�sater scrvicc. `�.���b�����d responsiblc and ahugcd lor same.
<br /> (G) '(hat aticr inslallalion,if mcicr or mc�cr box and appurtcnanccs arc buricd or damaged,lhc o�.vner,
<br /> ��� inspcciioo,w�nnc�ci ng orrJiscoi nc ct ng thclserv ca or�for�su I�o�tli rspumo crs as tlic xn i�ac may r yuirc.It�is also undcrstoed doring Ihc time that o�y�f�
<br /> may Iravc bccnsl.vdYtic MWU�v Ilnonbc rcqui�d to fum�islb�aicr Auring�he progress'of s'ucl impm�mNDs lo any wnsumcr`ult se supp�Y�µ�Y�hus1Fc
<br /> cut u�T,ar bc Iiablc fur any damagcs(ur iLs(aiWre to Jo so.
<br /> (µ, ntcicr(s)lo reglslcrlthlc aatcr wneumcd.�1�1 c M\VD shall not be hc J liablc for damagc by��atcr ur ot6cr caus'c¢sulting�fmmsdcfativc����mti nglor `
<br /> ndlapplianccs sl a I nol�bc pl�J as u basi�s(ur rccocuYnn ceuc o(�Jamaga as aforesaid!IICWa so�pplY of vatcr shal`�D ur bo intcrtu�cd`bY�c o1��1°(i"�
<br /> bc�hcld�o consi Wtcra baaeh of coNract an�hc prn of tlic b1WD c�in�yry way relicvc I�c consumcrs'xhcthcr�tenlant ar�'�nc�r,�Gum per(o�rtningS!I c�blc tinm
<br /> u6ligztion of such tcnnnl's or o�rncr's rnnlract. Watcr shall bc uscJ�6y applicant only on thc p«mises dcs'cribcd hc�cin. A nc�v applieation shall bc filcd
<br /> shoulJ watcr bc dcsired fur olhcr p�ciniscs allhaugh localcd on Imid dcuribcd hircin. ' '
<br /> (9) '1'hnt Ihe 111ND rStonnnen�s inslaliation of u pressure regulating valve. ApplicnN ackno�+IeJges in�ormaliun as to Ihe recummenJalion und
<br /> assumes rTl�c+ onsibilily fnr inslulling�r fniling ln install a pressurc reFulaling�'+��c on���e waler system to pro�ect it frnm hig��
<br /> pressnrc.�'_.� }� INT.
<br /> (1f1) cxpanslun'rnkWprcrcn�cxccss�c'1prcssureLnilJ-,uplcauscJby�hc�na�cr,hcatenr�pplin'n�acknonlcdgcsinformatianns,�o�hcrccommcml:nllun
<br /> nnd assumas full ruponsiLility(or inslallin�;or fniling m install a tlurnml rxpansion lnnk•����_�N�'
<br /> ��
<br /> - l ��� ,:.:1 I � i _)/ LOl'NO.: I t-�. UI OCK: .-._
<br /> SI:ILVICI'>ADDRHSS. � C 5 J��1 �I � � ". 1 '•- --
<br /> r PLAT NAMf::_�-!-` ���
<br /> CI�PY/5�1'A'Ifl'I.11' . �� C.Tr . - �.JL�f �-- � �
<br /> ONNHIi'SNnMG: �ll`r._. :�..1 -_���'.'._ii`.:�� 'iC'.�I�1i;' '- LfGALDf3SCILIP"IION:__ —
<br /> ONN[IL'tiAnUR1i5S:_',� , --� `' t::'J..�l f.?r vL- _ . .
<br /> '� • ',-�OG I3LDGPERMITISSUGDDY:
<br /> �.l_JL' �'C� .
<br /> CI'IY/5'I'Al'L'//.IP: C- '.,='Y'-" "I � -�
<br /> '_��� WPORhiATION LL•ITERGIVGN: ,
<br /> 'fhcprentiscsawtobcuscdtisa_�� •?�t5 �� . ,..
<br /> ��� t
<br /> ct�niac�s: � J_ _--.`-=.'��- �� C
<br /> snevicr:�rvrr: � � /a
<br /> �j (I)Scrviccinstallation&conncctionchargc .., ,�� �`J j �\�C. \,�
<br /> Ucvdupct Installcd: $:-'--•.\.
<br /> (2)Gcncral Pacililics conncclion char6� � �
<br /> Uistrict Inslallcd:_ , S___,-_--. L�,
<br /> (3)016cr
<br /> District Ins�allcJ I'vmrc: 5--�-J,_--=_-. \l,
<br /> "folal unount rcccivcd with apP��caiion ��j� Q�
<br /> 17'IS UNDGRS'fOOD that�his Applicalion,nitlwugh signcd,shall mt bc binding upon Ihc MUKILTLO WATCR DISTRICT until apptovcd by th^.DI�i�ID
<br /> 1
<br /> 1.ihc mmcrsigncd,owncr(or rcprescntalivc)of Ihc propettY dascribcd a6m�c,du hcrcby makc applicalion for installation of n I I .inch di fi,��l/vatcr supp�y l
<br /> sen�iceconneclion,incluJingappunena�ucs,`n Jallnecess:uXlabor.almy.ezpenses. ...
<br /> D:�Icd lhis �--� day af ; .
<br /> I {. •V � �"'� ! G9Lnn�T.:�, t
<br /> ,1PPLICAN�1'S'ti1GNATURG:_ G �
<br /> 5 �
<br /> i���� R.� V ,� �'v; ��i � ,_ ,
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<br /> Applic:mCsNamc(OlcascprinQ: . � r,. —�T I��1�7�� ��%�G� V �_��� , � �. , i (�:�.
<br /> - , i l- ., 6 ���{.h� L ���_
<br /> Applic:mCs Address&PhoncNumbcr: �`�� ��' �� '
<br /> ygg ,� N0�
<br /> CRc7tiSCONNHCTIONCONTROLSUMMN2YA5SfS5A1ENT�ACKPLOWkEQCCSInitials: �
<br /> Date: �i C G
<br /> Sizc oCDcvice: I
<br /> l��pc of Ucvicc:_�--- \_ !
<br /> :�PPROVk;II,:` �IUKILTEONATF.ItU151'Ii1C1' r� �.�
<br /> /i��/ _ Da�e: j� y'� Issucd By,. ,= _
<br /> 13 �: ''!,i i,.'��.._.--�.__ _—_.— — .
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