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<br /> DTT if:{LTEU �i'ATLR D[STRIC7' �J
<br /> APPLICATION FOR R'ATGR
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<br /> Metcr Sizc: � Servicc Address: /-� � � �� �' �� Acct.No.: � G I I "1 —
<br /> Number of Units: r ,�
<br /> i� `�vleter will be used for(che:k all that appl y):�Domestic irrigation _=Fire Service Fire Line V
<br /> 1 hcrcby apply for water scrvice and agrec to bc govemcd,in accordanee with the resolutions,rules and regulations of thc MUf:IL'CPO\VATER
<br /> DISTRICT(MN�D)pettaining to water service,noa or hereafter in effec[. The undersigned az o�mer or representative of thc hercin-described
<br /> prcmises hereb}•agrees as foilows: .
<br /> (Il The consumcr ag¢es to insiall,oporatc nnd maintain at all timcs,lhcir plumhing system in compliancc e�i0�the artent edition oflho Unifortn Plum6inE
<br /> Code as it pertains�01he prevention of contvnination,and pmiection from�hermal expansion duc to e closed sysmm thnt could occur wi�h�he p¢srnt or
<br /> fuwrc inslallntion of back0ou�Grcvrnttrs on Ilm consumer's scrvicc anNor at plumbing fixmmt.
<br /> (2) The consumcr flgrces to install all hackfloa�prcvcnliun astem6lia rtqutstcd by tl�c M WD,yid to maintein thosc bacA(low prevention asscmhlics in good
<br /> working ordec Th:assemhlies shall be of a r,Te,sim and mal:e appmved by the MWD and Ih:l4'ashin�ton Slate Depnnmant oC}Icalth Auihoriry�. Thc
<br /> azscmhlics shall bc inttallcd in accdtdancc w�ith all standards cs�a6lished by Ihc TiWD.
<br /> (3) Thc W ater mcmr w�ill not bc installcd until a wamr usc survcy haa becn submittcd by thc appiicant wd Uic Disirica Cross Conncction ConVol Sp:cialist hns
<br /> dctcrtnincd iCll¢customcr will nccd P inslall u 6a:k0ow�prwenlcr o�Ih:cusinmcr's sidc of ihc mcta.
<br /> (4) T6a:�hc wst nf any czlension of th=water scrvic[,rcncwa!,rcplocement or rcpair m rcach and servc Ihe property dcscribed shall he bomc by myscl(or
<br /> azsigns av nwncr(s)of�hc prcmises.
<br /> (5) Tha; all pipu,water mcasuring Jevices nnd olher connection equipmrnt upstream from�hc meter shell,aIler',iieir installution,be and becnme 6�c property o(
<br /> thc M1VD,suhjcct lo all iLs regulnlions pertaining lo watet scrvicc.
<br /> (Gl Tha:aftcr ins�ailation,if ineter or mcmr boz and appurtcnanccs are buried or dama@cd,the owncr,will be hcld rcsponsible and chargcd for samc.
<br /> (7) Tha:Ihc�1N'D,ils oRttrs nnd necn6,shall havc�hc nght of ingress nnd rgrcss to go upon Ih:prcmiscs wd pmperty dcscri6cd hcrcin Cor thc purposc of
<br /> insp_:tion,connecting or discannectino�he scrcice or far such oUier purposes az the scrvice may rcquire. It is also underslood during 6ie timc lhat any of
<br /> Ihe water maias may be out of strvice by rcason of any emergency or improvemen6 uulhorized bp lhe 1fWD,in any street or olher locution in uhich ihcy
<br /> map havc httn laid,lhc M WD aill rot b:requitcd(o(umish wattr du. ng 1hc progrcss o(such impmvcmrnu ro any consumer whose supply may ihus bc
<br /> cut oR,or bc P t61c for any damagcs for it.v failure to do so.
<br /> (S) Thx:the MW J shall hav:Wc ripht m ch;uige th:ra�es at nny time by Resolminn,to temporarily diswntmu:0�e service m consume�,and ao install ihe
<br /> m_ic�(s)to registcr:hc:ratcr cunsumed. Thc�1R'D shyl not 6c hcld liablc fur Jamagc by�ratcr ur o�hcr eausc resWting from dcfective plumbing or
<br /> appliances installed by the oumer or occupant on Ih:pmmises supplies ui0i wamr,and the(act U�at a;enls ottlie M WD map have inspmted Ihe plumbing
<br /> anu nppliances shall not bc plwJ az a bazis for rccovcq•in cuc of damagc az aforesaid. If Ihc supply o(�ralcr shall(ail or bc intcrruptcd by«uon of
<br /> :¢ndcnt,lou�p¢ssurc or olhcr causc w�ha6ocvcr,thc MND shnll not bc hclJ Iiablc for damagcs nor shall such fnilcrc or imertuption fcr any rtasonablc timc
<br /> 6:h_Id to constiWte a 6rcach oCcontrau on Ihe part o(Ihe MWD or in mp u'ay rclieve the eonsumer,ahelher�encnl or owner,Gnm pedanning lhc
<br /> obligatmn o(su:h tenanCs or oaner's convacC \4'ater shall be used br applicant only on Ih:premises described hereia A neu�application shali be filed
<br /> shnalJ waier Le Jcsi�cJ lor othcr prcmisc,although lo.atcd on land desc�ibcd herein.
<br /> (7) 'Clue Ihe�iR'D r.emnmenJs inslallalinn ufa pressure regula�ina vah�e. Applirant acknnn�ledges informnlinn as l0 0¢rccnmmendolion nnd
<br /> assnmcs G�II respnroibilitc fnr installing or faiiin��n install n pressurc rcpululin�,valvc on Ihc wnter system lo promrt i[(rom high
<br /> i � I presmre IM�.
<br /> _ Q0) 7'hc A1R'D ulilizcs chccl:rah'cs at�hc mctcr tn prcvcnt�rntcr rtturnin�tn Ihc Uistric�s mains. Thc�1ND recommcnJs installetiun of a�hcrmal
<br /> expansiom m�k lo prevenl exeessire pressurc 6uiIJ-up eauseJ br the x'nter healer. Applicont�ckDowledges in(ormntiun as Io lhe recnmmenJalinn
<br /> m�J assumu(ull responsibiliq�for instnlling or fniling lu instail c Ihermal expansiun tank_IM17'.
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<br /> SGRVICGADDR6S5: ��� �''�� 1� ' ���/ � �!� LOTNO.: � ➢LOCK: _
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<br /> CITY/STATElZIP: � -�� �7 PLATNMIE: -�� ^� � ,
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<br /> OWNF.R'S NAMP' '.� .' i.� �;.' . �.���.� �I I'�'::._'.tll ��, �,�_. � I�� ��'._. LF,GAL DGSCRIPTION: �/ _
<br /> OIVNER'SADDR[S5: .� t�'. .'�. ''`'� �.`� �%r J'/-/ _
<br /> CIT7'/STATf7ZIP: . - +'.` i 4'� •.. � �`�; � '" �LUG PERMIT ISSUGD UY: '•� ��� ��F�
<br /> Th�prcmiscs orc to bc used as a ='�` INFOIZA1ATION LETTER GIVEN:�
<br /> .l'F:RVICE Tl'PH� CHARGHS: ,/--
<br /> Devclopv Insulled: � (I)Service instullation S conneclian charge 5 7�3' �'Y�t
<br /> District Instal lcd: (?l Gcne:al Facilitics connation charg: S '-� �� �"�
<br /> District Installcd FuWrc (3)Othct S _
<br /> —'G ''• �IJ
<br /> Toml amount rcccivcd a�ith npplica[ion 5 3�3j•-
<br /> IT IS UNDERSTOOU ihat ihis Application,allhough siFned,shall not bc 6inding upon thc MUI:ILTEO WATER DISIRICT until uppmvcd by ihc DISTRICT.
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<br /> 1,Ihe undcrsigncd,o�mct(or rcp¢scnmuvc)of thc propctty dcscribcd nbo��c,do hcrcby'm:J:c application for insmllation oCa / -inch di:unetcr xater supply
<br /> scrvice wnnccuoq.induding appurlcnmccs,and all ncccssaq,labor..t mp cxpcnses. •; r'��
<br /> UateJlhis �` daypf _ =':.. � �'��p�'�'•
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<br /> APPLICANi'S'SIGNATUR[: � - � �' � - �"�—^"� l� r=��;'TJ
<br /> ApplicanCs Namc(picacc printl�. � "" ` • .
<br /> Applicant's AdAress d Phone Num6cr: � � ---+." � _�� � ;". ' i.�' . ':i;� _.. `'i �,—� �, 1:J .
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<br /> — CROSSCONNECTIONCONTROLSOMMARI'ASSESSMET"fBACKFLOWREQUIRED? ��S �NO �/�/pL �
<br /> l}pco(Dceicc t ��r` Sizcoflln'itt: CCSlnitials:� Uate: JY�j��'^" �
<br /> .�I'PROVED� 11iUli1LTEON'.1TERDISTRICT � .
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