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<br /> MCth.ILTEO.WATER DISTRICT �
<br /> A�PLICATION FOR WATER
<br /> � :
<br /> Metcr Size: `/� Service Address. �/��_�'� ��� , "' ` �!� "� Accc No.:��_� D
<br /> Number of Units:
<br /> `Meter will Le ueed for(ch.eck all that apply): �Domestic Irrigation _Fire Service _ _ Pire Line
<br /> I hereby apply for water service and agrce�0 6e govemed,in accordance with the resolutions,rules and regulations oCUte MUKILTEO WATER
<br /> DISTRICT(MWD)pertaining to water service,now•o�hercatler in ef@cL Thc undvsigned as ox�ncr or representative of ihe herein-described
<br /> premiscs hereb��ngrecs as follows; �
<br /> Q) The consumer egmes lo insmll,opera�and maintun n[nIl times,iheir plumbin6 system in complionec wiUi Ihe curteN edition of Ihe Uniform Plum6ing
<br /> Code a;,it pertains to�he preremion of contaminuion,und pmteclion fmm Ihertnal oxpwsion C�¢to a closed system thnl could occur with the present er
<br /> � (ututt ins�allation ofbackllow prcv�ntcrs on thc consumcr's scrvicc nnNor at plumhing fixmres.
<br /> (2) il¢consumv agrees to install all bacAOow prevention as;emblies requesled b}'l6e MWD,and�n maintain�hose backOrw prerention azsemblies m good
<br /> working ordec Thc asscmblics:hall 6c of a type,sim anl makc opprovcd by thc M\W and thr.VJashington Stnte Depznmen[of Health Aulhonty. The
<br /> asscmbl�cs shall bc insmlicd in�ccordancc wilh nll s�andarJs cste6lishcd by tlic MWD.
<br /> (3) The w�.¢r mner wili no[be inscalled until e wafer use scrvey haz bcen submitted by We applie;mt and the Distric6 Cmss Connection CnnVol Speeialist hav
<br /> detertained if Oic customer will necd m insv' �back0ow preventer on Ihe cuslomer's side of Lic memr.
<br /> (4) 7liat�he cost of any extension ef ll¢water scrvite,renewal,replacemrnt or repair to rcach and smc lhe propeny descr.6eJ shall 6e bome by mysd(or
<br /> �ssigns az owncr(s)o(tlic p¢miscs.
<br /> (5) Thnt nll pipes,waler mcasuring Jevices ond olher conneclion equipment upstrcam fmm Ihe mcter shall,afler Qieir installntion,6c and become the properq�of
<br /> tlie M WD,suhjttt to nll iLs rcgulatians pcnaining lo wa4r scrvicc.
<br /> (6) Thtt aller inttallation,if mctcr or mctcr box and nppurtenwccs arc buricd or damagcd,�hc uuner,will 6c held rcsponsible and char6cJ far samc.
<br /> (7) That thc M WD,i's otLccrs and agenLs,shall htvc�he right of ingress and cprcss to go upon Wc premises ond propctty dcscribcti hcrein for Wc purp d
<br /> inspection,connecling or disconnecting ihe scrvice or for such otlicr pumoses u�he service may require. It rs also undersmod dunno the time that�-��� d
<br /> Ihc Halcr mains may bc out af scn�icc hy rcasan of uny cmcrgcncy or impmvcmcnLs nufhoriz,:d by thc'd WD,in any s1¢c[ar otlicr Iocaiion in which tncp
<br /> m:rc hm�e becn laid,We MWD will not bc required lo Cumish tvater during Ihe progrcss of such imprm�emenB to eny consumer whos:supply may[hus bc
<br /> cut n(T,nr bc liahlc for any damagcs far iLs failum lo Jo so.
<br /> (R) l hu[thc MWD shall havc II¢right lo ch�ngc thc ratcs at any timc by Rcsolution,m tcmporarily discantinu:Ihe scrvicc to consumcrs,and to intiall tl�c
<br /> mcic�(s)to rcgistcr tlm walcr consumcd. Thc M WD shall not 6c hcld liablc for damagc hy watcr or othcr causc resulting from dcfcctivc plumbing or
<br /> appliances installed by the otmer or occupant on Ihe premises supplies w�ith water,nnd liic fac;that ngenLs ef Ihe MWD mar have inspeckd the plumbing
<br /> and applianccs shall not bc plcad as a 6azis(or recovcry in casc of damagc u aforesaid. If Ihc supply of watcr shall fail or bc intcrtuptcd by rcaz�n cf
<br /> accidcn4��w'p«s:urc or o0mr causc xhuLsncvcr,Ihc M�W shall not 6c hcld liahlc(or damages nor shall such fuilurc nr intcrruptian for any rcasonablc:imc
<br /> h:I�cld lo constiWtc a brcach of wniract on thc pan of lhc MVJD or in any way rclicvc tltc consumcr,whcthcr icnant or owncr,Gom perfortning Ihc
<br /> oblieation of such tcnanCs or ox�nc�s contract. lVatcr shall b:uscJ 6y applicant only on th:prcmiscs dcscribcd hcrtin. A nnv applicatian shall bc filW
<br /> shnuld�eatcr 6:dcsireJ fnr oil¢r prcmiscs nllhnurh Incalcd an land dcs:.ribcd hcrein.
<br /> (9) 7hat thc�111'D rcrnmmcnJs installalmn ofa pressurc rcgulating vaWc. Applicnnt ocknoo9cdgcs informntion as to U�c rccummcndalion and
<br /> - assumes full respnnsi6iliry�fnr inslullin�or failin��u instail a pressure regulating valve on the�vater system In pro�eet it(rora high ��
<br /> � I pressurc.�� �IN7'.
<br /> - (10) The ARVU ulilizcs cLcek vab�es al lhc metv ln prn•cnt�eatcr rcl:Wrning to ihc Uislricis mains. Thc�t\VD recommends ins�nllalion of a thcrmal '
<br /> etpansion tank lo prevent excessirc prasure builJ-up caused 6r Ihe walen c�aler. Applicanl acFnewleJ�rc in[orma�ion as to�he recommendaliun
<br /> anJ assumes hdl responsi6ilin�lor in�talling or fniling In ius)nll a Ihermnl ezpansion tank '_`'[?�C.
<br /> i
<br /> SCRVIC[AUDRCSS / - S:.` � '�� �"/• �� LOTNO.: OLOCK
<br /> .� _ �-�,�,;/-":'.'/'�.v ;.�. .�
<br /> Cfft7S�ATL'1ZIP � � ��� )� �� '� PLATNMIE '�' �.-� � �
<br /> 014NF:12'SNA�1L--- L.`I�.(�C�LCL'�IL2 CIJ2Q�J� .LEG�LDGSCRIPTIO /��� ; / �. .- /) ..,� _.---��
<br /> o�w�i.s nnon�.ss: /.-�l�'�.:��s .��CGtP.!�-%_,'i y�i �-�i/-' /�7
<br /> C17'Y/STA'fPJLIP: �� ���� � ` � � � � " �J� DLDG PGRA7IT ISSUED UY:
<br /> Thc prcmiscs are�o hc uscd as a ���r INFORMATION LGTTER GNEN:
<br /> tiGRVICF.9'1'PIi: CIfARG[S' %�r.ln `�- �
<br /> Dn•doper Insmllcd: (I)Scrvicc installatian S connccc�m ch�r�e 3 �
<br /> I)istrict Installcd V (?)Gcncral Pucilili[s connwlion chmgc S_ '�`��
<br /> Disirict In5taIlcJ Fuwre (3)Olhcr �
<br /> Tocal amount«ccivcd wilh npplicauun S _r^�T
<br /> ;T IS UNDERS�OUD that tliis Application,altliough signeQ shall not b:binding upon thc MUKILTEC'WATC•R DI57RICT unt1 npprovcd by�he UISTILICI'.
<br /> - �/u
<br /> L�hc unJcrsigncd,o�mcr(or represcnmtivc)of th:property dcscribed a6ovc,du hcrchp m�lc nppLoation Por inslxllntion o(a _-ineh diamcter wa�r.supply
<br /> scrvitt conncction,including appurtcnnnccs,and all ncccst'vy.labRJ nt my cxpcnsu. PA�D
<br /> �a�cd this _ _ dar of � . � - �
<br /> �,rrucnti�rs•sicNnivas: -_ ' � �AR 2 N ��;7
<br /> � n . ✓�p; � Im � �
<br /> Applicanl's Namc(plcasc prinQ: -' �
<br /> Applican!'sAddressSPhoncNumbcr. ...: ��'� . � ' '.. ' � .� . � . �. i nln� �� clnrr.� ni�-.. ,,
<br /> -• � _ h,,.:,i1?c., G. .._,. . ....:.!.,i
<br /> CROSS COnRJGC7'ION CONTROL SUAtA7AR1'ASSESSMENT UACF:PLON'RFQ�IIRGD�_�� �5 ^ NO3�4}/C t
<br /> 'I'}pc of Dcvicc: Sizc of Dcvice:__ CCS initial;:L�—� Datc:
<br /> AI'PROVED•�IIi:ILTEO R'ATIiR DISTRICI' �� �`_�
<br /> �� /2� o-P.o7
<br /> ltr. �"'!, "�`� Datc�. �' �� Icsued[3c�.__
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