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' pfUI:ILTGO N'ATER DISTRICT V
<br /> APYLICATiON FOR WATGR
<br /> n �� � i^ �', ; � �
<br /> Meter Size: �✓� S:rvice Address: �` �' � � -' ` �• Acct.No.: � Q j�� ^
<br /> Number of Units: 7 V
<br /> � 'Meter will be usr,d for(check all that apply):V Domestic _Irrigation __Fue Service Fire Line
<br /> �
<br /> I iicrcby apply for wa[er service a�id agree lo be govemrd,in accordancc w,. � ,ic rcsolutions,rules and regula[ions oC�he MUI:ILTEO WATER
<br /> DISTRICT(MWD)penaining to water scrvice,now•or h:_eafter in e(icct. The undcrsigned as oemer or rcprcsentativo of the hcrein-described
<br /> premiscs hereby agrees u(ollows:
<br /> (I) The consumer agrees Iu insiall,opemle and maintain at all timu,Ihcir plumbing sys�em in complianee wiih Ihe wnent edi[ion of the UniCortn Plumhing
<br /> Code as it peneins m�he prcvemiun oCconmmination,end pmketion(mm Ihermal ezp;uision due ro a closeJ system thal wuld occur wi0i Ihe p¢srn[or
<br /> (uWm instellation of bnckilnw prcvrnt[rs on thc wnsumcr's servia andlor at plumbing fizNru.
<br /> ('_I The eonsumer agrces tu inslell nll 6acktlow prcvenlion assem6lies tequcsted by ihe 1�1 WD,m�d to maintain Giose bacAllow pmvention assemblics in good
<br /> wnrkiag ordec The assemblies shall be of a t}pe,siu end make approved b}�Ihe MWD end Ihe Washingtun State Depenment olHealth Authorit}. Thc
<br /> asscmbliu shall 6:mstalled in ecwrdancc will�all standards csta6lishcd by ihc MWD.
<br /> G i The H�ater meter will not be instalied until a w�attr use survey haz heen submitted by�he applicant and Ihe DistricB Cross Connection Control Spe:ialis!h:s
<br /> determined i(Ihe cuslomer will nted to install a b¢cAOmr preventa on Ihe customer's side of the mekr.
<br /> (�� Tha!Ihe co4 o(any exlrnsion of Ihe woter scrvice,renewal,replacemem or repair m reech end srne Ihe pmpert}'described shail be borne by my>el(or
<br /> issigns as owner(s)of the pmmises.
<br /> (i 1 Tha:all pipcs,watcr rzcasuring dcviccs and olhcr connretion cquipmcnt upstream fmm�hc mcler shall,a(trr Ihoir mstailation,bc and 6ecnmc�h[prcp�rry�oC
<br /> Ihc MWD,subj¢t to a�l ils rcgulatio�s pcttaining to watcr scrvicc.
<br /> !bl TSn:aftcr insmlletion,dmcter or mcter 6os and appuncnmus are buried or damagcA,Ihe owncr,will be held rcsponsiblc and chmgcd(or samc.
<br /> f7) 7'ha�Ihe Ml9D,iLs otTittrs and agrnt . hall have�hc right of ingress and eerus to go upon the premises and propeny described herein(or the purposc af
<br /> m,p�c�inn,connecting or disconnectin m scrvia or for such other pumoses u�he servic:mop rcquire. It is also undersrood during�he time that any of
<br /> ihe ualcr mains may bc out of scrviec oy reason o(nny cmer6rncy o:improvemenLc aNhoriud by th:MWD,in any svcct or olher location in whieh th:y
<br /> mrp� hxve Seen laid,the MWD will nat b:requirrA lo fumish water dunng Ilm progrecs a(suth impmvemenLs lo any consumer whose supply may ihus bc
<br /> - cut nf(,ot bc liahlc(or any damagcs fo�iB�ailce 10 do so.
<br /> (R) 'fha:Ihe M WD shall have the tight lo ehangt Ihe rates at my time by Resolution,to t:mporerilp discantinue Ihe scrvice Io eonsumers,and to in:tall ihe
<br /> m:1.�(s)to mgis�cr Oic watcr eonsumcd. T6c A7WD shall not be hcld linblc fo�damage by wntcr or uthu cause rcsulling fmm defccliv:plumbm�or
<br /> xppli�nres installed by the owner or occupant on tlte premizes supplies with water,and 1he Cact�hat agenis of Ihe MWD may have inspected 1h:plum6in;,
<br /> emd,ppliunccs shall nol bc plcad ns a basis for mcovcry in tase o(damaec ns a(oresaid. If tlu supply of rvatcr shall fxil or bc intcrtupicd by rcasun of
<br /> acnd:nt,lnw�pressure or other cause whatsoever,We MN'D shell not bc held liable(or Jamuees nor shall such failure or intermption for nny reuona6le timc
<br /> bc hclA to cons�iw�c n brcach of conuact on Ih:pan of Ihc MWD or in any way rcliove�he consumor,whelhcr�cnant or oxncr,from pcdorming�hc
<br /> n66eation o(such tenanYs or o�mer's contrarl Water shall b:used bp applicant only on th:premises dascribed herein. A new opplica6on shall he filed
<br /> shnuld watcn c�dcsired forothcr prcmiscs alfhough locatcd oo land dcscribcd hcrcin.
<br /> (9� '1-6a[Ihc 1fR'D recommfnds installalion nfe pressurc regala:in�rah�c. Applinnt acAnmvlcdgcs informalion ns�o�hc rccommcnJnliun and
<br /> � nssumcs full rcspnnsiFili�c for installing nr failin��u install a pressurc reCulalin�valrc on thc x'a�er spstcm In proteet it from hi�h
<br /> , i pressurc. t�T.
<br /> - 110) The A1�YD utilizes el�eck vaWes at lhe meler Io prerrnt wnter reWrnin�m Ihe Uistricls mains. The AS\VD recommenJs insmllation of n therm�l .
<br /> cxpansiim IanA�n prevenl excessire prsssure 6uild-up tauscJ by thc a'u�cn c�attr. Applican�a[L:nnwledges infarmxtion as lo lhc recommenJa�ion
<br /> and assumcs full respunsibilil}'fur ins�alling or failin�lo instnli n tLcrmal ccpanaion�ank I\T.
<br /> Slil:\9Cf:ADDRESS: �� �'� ••% j'�;" � �� ; `/. LOTT:O.t ^ [3LOCF:�
<br /> CI'Pl';ti7�ATEJZIP: � � �� � •���C?� PLATNAME. �-y- � . `_ . �
<br /> O1i'NEIYSNAME: ��� � '�1�•�:�-�f 1 �1;- _,`���:�'....�1'- i : • I:EGALDESCRIPTION: �iJi '{��
<br /> J/
<br /> 011'NFi1L'S ADDRBSS .��' � ,--� �." � ' :�.1�.. _ .-
<br /> '[1J. .
<br /> �I7lYS'1"A7FILIP: • . �� 1�� � ' ' �' ����' BLUG PLRMIT ISSUED BY: _
<br /> '(ispremisesarctobeused�ua "�� WFORMA'fIONLGTfERGIVEtJ: _ ____. _ .
<br /> Sl9:\'ICP TYPG �ji�SGFS
<br /> Dcrcloperinsmllcd V (I)Scn•iccinsmllation8connationchargc S�5�����
<br /> Uisuict InswlleJ: . ('_)General Pacilities connection charg: 5 y ���""� ��_
<br /> DisuicllnstallcJl�ulurc: (i)Otltcr S_ - y- -- � .
<br /> Total mnount rcccictd x�ith applicaUcn 5 �f�S�•��
<br /> ❑'Iti U1I)ERS"I�OOU that thu Applicmion,ahhnugh sign:d,shall not 60 6inding upon Ihc MUI:ILTEO N'ATF.R DISTRICT until apomvcJ b� �hr I Y,'.����!11 �:
<br /> `iF
<br /> I,ihc undc�signed,owncr(or mpresentaiiec)oflhe pmpeny descri6ed a6ove,do hembr make npplicalion(or insmllation oC a �/T •�ac,�,e�iani,tu,�can::sqn�:>,
<br /> sen�iac ronnccyon,induding appuncuanccs,and nll nccessan�labo�.al mp cxpensa. i�r�o "— �I
<br /> �mcdlhis " do)'a(_ � . '� `' O '�''"JS� ' ('�
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<br /> APPLICANTS'SIGNATURL:_ - - ` � �L�`-'y: �'-'�'
<br /> Applicant's Nemc(plcazc print): .� r ��� - -
<br /> Applic:mPsAddmssfPhoncNumbcr..-�� . .. �- � .�,�� - � !��� i ✓C��` ,`! _ � -
<br /> CROSSCONNGCTIONCONTROLSUA1MARl'ASSES5MENTOACF:FLON'RGQUIR[D7�F.S /� NO / .
<br /> 'I\�p:afDcvicc SiuofDcvicc: CCSinitials:_�< � Date:/,7/�J
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<br /> nrrit0\'CD: NU61LTk:0 K'ATGR UIST7tICI
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