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MUKILTEO R'ATER DISTRICT O
<br /> APPLICATION FOR WATER �
<br /> > �Meter Size: ���G Service Address: /- �" —� r' � ��' ' ' Acct.No.: � Q � ,3__,
<br /> Numbcr of Uni�— I
<br /> .�� N.eter will be used for(cheok all that apply): L� Domes[ic Inigation Fire Service Fire Line �!
<br /> 1 hcrcb}•applp for water sen•ice and agrec to bc govemed,in acwrdancc with th:msolutions,rules and regulations of the MUI:ILT'EO N'ATGR
<br /> DISTRICT(MN�'J)pertaining to w�atcr scrvicq now or hereafter in effect. The undeaigned ae owner or representative of lhc hcrein-dcscribcd
<br /> prcmises hereby agrces as follows:
<br /> i I j Th=emuum[r agrecs to insmll,operate and mainmin et all timu,Iheir plum6ing syslem io compliance with ihe wrtent edilion of the LJniform Plumhing
<br /> Code at it pertains tn tlie prcvrntion of contamination,and protection fmm Ihertnel ezpansion due Io a closed syslem that could o:cur with�im prt,en;o:
<br /> (uWrc installation of backilow p¢vcntcrs on Ihc wnsumcr's scrvicc nnJ/ar at plumbing Gztu¢s.
<br /> (2) The consumer nerees Io insL�ll all bacAflox�prcvrntian assemhliu¢qua[:d by 1he MN'G,and to maintain�hose baekilo�e prcvention sssem6li�s m gwd
<br /> working ordec The usemblie:shall be of a ryme,sim and maV:c approved by�h:MH'D and ihe Washingron State DepanmeN of Health Authoriq�. Th=
<br /> atsem6lia shall b:inttalled in newrdance wilh nll standards estahlished bv 1he MWD.
<br /> (;I The wmer meter wiil nnt oe insialicd until e water use survep has 6ttn su6mitted hy Ihe applicant and lh:DisvicLs Cmss Connecdon ConVol Specialist hu
<br /> dcicrtnincd if Ihc customv will nmd to install u bacAllow prcvcnRr on Ihc cusmmcr's side o(Ihc macr.
<br /> (�r That the cost of any extension o:1h:water scrvice,renewal,replacemem or repair to rcach ond serve�he propen}'d:scribed shall be bome by mysdf or
<br /> assigns as owncr(,)of Ihc prcmiscs.
<br /> (5 i Thnt ali pipa,wam;mcasunng dcriccs and other cpnncction cquipment upsveam tmm Ihc mcttr shall,aRer their installation,bc and 6ccomc thc pmp:m�of
<br /> thc M�1'D,subjcct Io all ils cegulations pertaining W watcr servicc.
<br /> (G� 7'hai a(tor installation,itmeter or memr box nnd appunenances nre 6uried or damaged,Ihe owrar,will bc hdd rcsponsible and charged for same.
<br /> (?j That th:MWD,iLt olfirers and agcnts,shall hnvc thc right o(ingress'and t@ress m go unon Ihc prcmiscs:md propcm�dcuribed hercin for the purpose o!
<br /> insp:clion,connecung or disronnecting Ihe service or for such olher pumoses as Ute service ma)'require. It is also undeatood Juring Ihe time lhat ang of
<br /> Ih=watcr mains may bc out of scRicc by rcason of any cmcrgrncy or improvcmcna au�horiud 6y lhe MR'D,in any strect or othcr Iocatia.`n which Ihc��
<br /> ma��havc hccn laid.thc Ml4D wil I not b_rcquircd to fumish aattr during tlm pmgress of such improvcmcnis to eny consumcr whosc supplp may thu�.h:
<br /> cut o(�,or bc liablc for any�vnagcs for iLs(ailurc to do so.
<br /> (fi� �I ha:�he M\9D shatl have 0¢ri@ht Io change Ihe tales at my timc hp Resolution,to tempararil}'discontinu:Ihe service to consumers,ond to ins:all Ihc
<br /> mcicr(s)tn«gistcr tlm watcr ronsumcd. TI¢MWD shall no[b_hcid Iioblc for damuec by watcr or o�hcr causc rcsulting fmm dtfcctivc plumbing or
<br /> applianccs installcd by thc o��ncr or occupanl on lhc prcmisos supplics x�ilh watcr,ond�hc fact Ihal agen6 of Ih=MWD may havc inspccttd the plombinc
<br /> and�ppliances shall nn�be plcad at a basis for rccoveq'in cas:of damag:as aforesaid. If the supply of water shall(ail�r be intertupted by rease i of
<br /> a::iJrnt,lou�prcssurc or other eause w�im6nevcr,lhc M.\4D sh�ll not bc hcid liabic far damagcs nor shull sueh failurc or inlcrruption for any rca onahie vmc
<br /> h::h::ld to eonstiwte a 6rcach a contract on Ifm pan of Ihe MWD or in:u�y way rclievc lhe wnsumer,whelher�enanl or o�mer,from p:rformmg�lie
<br /> ,�bLcation of such tcnanCs or nwncr's contract. R'atcr shall b:uscd bp appiicant only on 1hc prcmiscs dcscribed Isrcin. A ncw applicacion shall L-filcd
<br /> shnuld watcr b:dcsircd(br olf¢r prcmiscs althouFJt locatcd on IanJ dcsuihcd hcrcin.
<br /> (9� 'Plmt tlm�IWD recommenJs insmllation of n pressure regulating��ulve. Applicant neknowleJges informmian as�a Ihc recommendalion unJ
<br /> .� ussumcs full responsibililr fur insWllin�or(uilinF in install a pressurc reguleting valve an the�ratcr system to pro�ttt it frnm hi�h
<br /> , prasurc. IN�I'.
<br /> Q0) TLe �TN'D ulilizes clmck valres al tlic meter�u prevent�rater re�urnin��u l6e Uistricls mains. The ASWD reeommends installation of a therm:il �
<br /> espansian�anA In pre��enl execssive pressure hnild-up rauseJ bc theo'nhr heatre Applicunt ncAnowleJges in(ormetion as to O�e rernmmenJ:�lion
<br /> anJ assumes tull respnnzihili�c fnr inslnliing nr faiiing tu instail u lLermnl e:pansion Iank.__I�T.
<br /> SiIR\'ICGADUR[SS: �- -' ' LOTNO.�._ � �LOCf:' __
<br /> .�.%�.�. _�'."•� PLATNAME: % • . . ..�;�
<br /> U��7/SThTPIZII - �' � -
<br /> '� ' �� ' � � '!/ LEGAL DLSCRIPTION: �- "�-'��
<br /> C��WBR'SNAMC , � �-� ' —
<br /> ., �.._ .�v�
<br /> O1FkER'S ADDRCSS: °` ' �'�" -- - .
<br /> �����}'/tiTATE/ZIP: � � � ' � 6LDG PF.RM111T ISSUED BY:
<br /> "fhc prcmisa arc to hc uscd as a -'�r _. __ RiFORMATION LETfER GIVEr: --
<br /> tii_RVICF.TYPF:.. C�IARSi,ES�
<br /> .>7��:?'.i
<br /> U:vcluper Inswlled: � (�)Scrvice inst.11ution 6 conncclion ehar6c S _
<br /> ..` ..�.(}�i
<br /> District lnslallcd: (?)Gcncral Tn:ilitics conncnion chargc 5 � - �
<br /> � Dislri:t Inslallcd FuWre (3)OIIRr �
<br /> ITota!amount tcccivcd wiih npplication b
<br /> I"I'IS U�UGRSTOOD ihat Ihis Applicatian,although siFned,shcll not 6:binding upon thc MUI:ILTEO N'A1'ER DI57721CT until approved by tlie DISTRICT.
<br /> -',iu
<br /> L the undersigned,o��na(or teprcsentative)of lh:pmpertr.escribed nbove,Jo hereby ma{:e application for installation of a - •inch diarneter x�amr supply
<br /> s:rcicc conncuion�including appnrtcnanccs,nnd all ncccscnrr Inborpt my cxpcnscs.
<br /> U�,iicdlhis_�__dayof . � . . '�'c
<br /> \I'PLICANiS'SIGNA7URF � - -�' � ' '' -n+—I_-.��,
<br /> � � L�� �� I �
<br /> �lppli:�nPsNamc(plcascpnn�)�. -. . ' . . ` r�9�7G,,cs I )I
<br /> .\ppG:m�I's AdJrcss d�fhonc Numb r _ - � - �I -_- ` J
<br /> � . .�.. .� ` � . .' ' ----
<br /> i'IbJSS COhRJECTION CONTROL SU:dMAFY ASSESSMENT BACI:FLON'REQl1IRED? yES � NO G.����
<br /> 'i���p;of Dcricc:__ Siu of D:vice CCS lnitiels: � Dute: �/-
<br /> T�
<br /> ,\I'1'Ii0\tiD: �UF:ILTCOYVA7'ERDISTRICI' .
<br /> [lc..���� Date y/?li�cJ�� l __ Issued R�•._. _-�,
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