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<br /> � � '+ f' MUHILTEO WATCR DISTRICT �
<br /> APPLICATIO�FOR�i'ATCR
<br /> �4cte:Size: -/�� _ Service Address: ��'�!%� r% � ia-, Acct.No.:�Q_LL� ^
<br /> Numbcr of Units: �
<br /> � �teter will be used for(chec4:all that apply): V Domestic Irrigation � Fire Service F've Line
<br /> 1 hereby apply for water sen�ice and agrec to be govemcd,in accordance witlt the resolutions,rules and rcgulations of the MUICILTEO N'ATGR
<br /> DISTRICT(MWD)pertaining to water service,nok�or Fcreafter in c(fcct. The undersigned as owmer or representative of the herein-d:scribed
<br /> premise,hercby agrecs as follows:
<br /> (I) ihe eonsumer ag¢es to insiall,operate and maintain el aIl times,Ihcir plumbing system in complianee wilh the wrtenl edition of the L)nifortn Plumbmg
<br /> Code as rt p:nains to In:prevention of conmmination,and pmtection fmm lhermnl ezpansion duc to n clased system Ihat could o.cur wilh Ihe p¢sent or
<br /> fumr<inslallalion of backOmv prevcnters on Ihe cansum:r's servicc andlor at plumbing fixWres.
<br /> (]) The ennsumer a@ttts to irt�tali all bacAflow prn•ention assem6lies¢qucsted b}�Ihe MIW,and to muintam Ihose back0ow prevrntion assemblies in eooC
<br /> wor{:ing ordcr. The asscmblics sh311 be of a type,sis nnd moV:c appmved hy thc MWD and ihc Washington Stau Deputment of Ftexllh Authorip�. Thc
<br /> assemblies shnll 6e installed in accordance wilh aIl standads esL+blished by Ihe MWD.
<br /> (+I The a�ater meter will no;b:insmllcA until a water use survep hu becn submiLLed by lhe applicant and the Districis Cross Connection Conuol Specialist has
<br /> dctcrmincJ if thc wstomcr will nccd to install a 6acAllow ptcvcnkr nn Wc customcr't sidc of th:mcttr.
<br /> (A) Tha:Ihe eost of any exmnsion o(Ihe water scrvic0.«newal,replacement nr«pair ro rea:h and sen�e the property Jeseribed shall be bome by mysdCar
<br /> acsigns az owncr(s)of thc premisei.
<br /> (>) That aIl pipes,watcr mcuunng devices and otlxr eonnection cquipment upsveam fmm th:mcicr shall,a(mr thcir instailuion,be and becomc thc prn,_ny ol
<br /> thc MWD,subjcct to all iLs rcgulations pcnaining tn watcr srn�icc.
<br /> (6� Tlia:aRcr installation,if maer or mcicr bos end uppuncnanccs arc buried or damagcd,thc owncr,will 6e held¢sponsible and chugcd for samc.
<br /> (7) Tha!Ihe MWD,i6 o(licers and agenLt,shall have Ihe nght of ingmss and egress lo go upon'h:premises and pmperty described hercin(or the purpose of
<br /> insptttinn,connecting or disconneping Ihe service or for such other pumosa as Ov^service inay tequire. II is nlso understood dunno tlte time�nat mp�of
<br /> Oic wattr mains may bc out of scn'icc by reuon o(any emcrFcnc}�or improvcmcnLs aulhorimd by the MN'D,in any stree[or othcr locauon in which thcp
<br /> map hnve been laid,tlie M WD will not b:rcquired lo fumish water during Ihe progrus of such impmvemen6 m¢ny consumer whote supply may thus bc
<br /> wt ofi,or 6e liabic for any dama[:cs for i6 failurc to dn so.
<br /> jfiJ That tlic MWD shall havc�hc rigt:to changc�hc ratcs at any iimc b}�Rceolu�ian,to tcmporarily discontinu:�hc s.rvicc to consumcrs,and to instail Oic
<br /> mcicr(s)w mgislcr Ih;u�atcr consumcd. Thc M WD shall mt be hcld liablc for datnagc by water or ollur causc rosulling fmm dcfcc[ivc plumbing or
<br /> applianccs installcd b��It�c owner or nccupcnt on tlre prcmises supplics wilh��alcr,and thc fact Ihat aecn6 of�hc MRm map have in,pccicd thc plumbmg
<br /> and applinntts thall not bc plead u n 6atis for mcoveq'in cue of damagc ac a(orcs�id. If Ihc supply of water thall fail or bc intertupted by reson of
<br /> uc;.idcn4�nw pressure ar oihcr causc whaBowcr,�hc MND shall not bc hcld liahlc far demugcs nor shall su.h failurc or intcrtupuon for any rensonahlc nmc
<br /> bc hcld tu constiN�c a trcach of conuact on thc pan o(�hc MWD or in mp way rclicvc th:cansumcr,x�hc�hcr�cnwt or ownc:,Cmm performing��c �.
<br /> obligalion of such icnanPs or owncr's contract. q'atcr shall h:uscd by applicant only on Wc pmmiscs dacribcd hcrcin. A nce�application shall hc filcd
<br /> should���aicr 6c Jcsircd far olhcr prcmiscs althouEh lowtcd on land d:scribad hcrcin.
<br /> (9) Th�[the MR'D rtcnmmends inslallulinn of a prtssure re�ula�in�valve. Appiican[neknoeleJges infarmetion as lo the recammendation and
<br /> .- assuma full remonsihilit}'for installin�nr fniling m install a pressurc rc�ulalin„valvc on ihe wa[er syslem tn protect i[from high
<br /> ' j pressurc � INT.
<br /> _ � (10) The 11N'U utilius cluck valres nt Ihe me�rr Io pro�tnt�rmer returning m the Uistricts mains. The�1N'D rreommends Instnlla�ion of n thennnl
<br /> e:pansion Innk In prn�cnt cxcessirc pressurc buiW-up cniucJ br Ihc walcn c�aicr. Appliwnl atknowlcJgcs informution es tu Ihe recommendalinn
<br /> :,nd auumes full respomibililc fnr inslallin�or failin�to inslull u lhcrm�l c�pansinn tanl:. INT.
<br /> i �
<br /> SFR\'ICEADDRESS: =-�''��� ' `'"' LO'i NO.: `%� Bf,OCK:
<br /> v;� � ,.,. �, :�?�.J"r T �v-.7 ..,. -
<br /> CITI'/STA7ElZIP: PLATNAME: -'� � � �
<br /> OIVNER'STAME: ' ��� � �� 4%= �' � �� LF.GALDESCRIPTIOt::
<br /> Oli'NGR'S ADURESS! •_,:� :`.i.� >. '. �'} ;)� ✓a��� ___
<br /> CI"Il'/STATG2I1': .. - �� ., � , - - " ULDG PLRMIT ISSU[D I3Y � —
<br /> i
<br /> 'I h:prcmiscs mc to b:usod ns a -'�/' INFOfN1ATION LGTTBR GNHN:�
<br /> SfiRVIC['fl'PF: CHARGF_S:
<br /> Dcvdoper Ins�nllcd: V (I)Scrvicc instnllntion S conncction chnrgc s�f33�o�
<br /> ��..,, ...,. ,—
<br /> Disvict Installed: (2)Grneral Fncilities connection charge S " �- ��� - '_
<br /> Disuict InsmlLd Fuwrc (3)Olhcr S _ _
<br /> Total:unocnt rcccivcd with application S_..�'9���U�'
<br /> IT IS UNDL-RS7'OOD lhat this Application,alWouch signcd,shall nat 6:binding upon�hc MUI:ILTEO WA7ER DIS7RICT until appraved by th:DISTRIC'i.
<br /> ��
<br /> I,Ih:undersiFned,o�cner�or represrnm�ive)of�he propeny descri6ed abore,Jo hereby mnAe applicatinn for insmllauon of a ' -inch diomettr water supply
<br /> scrvice wnn:n�au;induding appuncnanas,and all ncccssary�laporyt my cxpcnscs. �_,_,•L i- r"'�
<br /> Datcd lhis � duy of "� ' . j �
<br /> Ai PLIC WT3'SIG��ATURC �'�` ���. _ 'l�� I LI� �lI,�lL^4 ��
<br /> ApplicanCs Namc(p;casc pnnQ. - - "- - � '-L �� � L _
<br /> Applicanfs Address&Phonc Numbcr:�. ' � _ � '���'• � .�:-��' �- �-'�-� � . . � -.
<br /> � i �� C
<br /> , CROSSCO�'NGCTION.0 NT OLSUMMARYASSESSMENTBACI:PLOK'RGQUIRED7 S� YES �NO /J �!,t� � �� �W�: �'
<br /> T}pcofDcvicc: v��� SiuofDevicc CCSlnitials: `, 'rG" Dnte: �-'� �j�✓r C+`
<br /> `\� /� V
<br /> APPRUP�F:D• ,� NUIi1LTE0\\'ATGRDIS7'RICf '�'
<br /> ��: i/ ^—• n��: � G'' ��.r 6 rss��a a>: _
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