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<br /> ' 91liI:ILT60 WATER DISTRICT �)
<br /> ,1PPLICATION FOR WATER J
<br /> Mcter Size: -��� , Servicc Address. I ��� �I N�" 1 r�! f,:�✓ �:� Acct.No.:��_3�_ (�,7
<br /> NumberofUniu: � V
<br /> 'Mcter will be used for(check all that apply):�Domestic Itriga[ion Fite Service Fire Line ��
<br /> 1 hcrcb��apply fcr water service and agree to be govemed,in accordnnce with thc resolu[ions,rules nnd regulations of[he MUKILTEO WATER
<br /> DISTRICT(M WD)pertaining lo water service,now or hereafcer in effecL The undersigned as owner or representative otthe herein-described
<br /> prcmiscs hereby agrecs as follow;: '
<br /> (i) Th:ennssmer agmes lo inslall,operate and maintain at ull tim[s,�heir plum6ing system in complianee with Ihe curten[edilion af Ihe Unifortn Plumbin�
<br /> Code ns it pennins m Ihe prevrntion of contamination,and pmtection fmm Ihertnal ezpansion duc to a closed system ihat could ocar wi�h Om present�r
<br /> fu Wre installation o(bacl;ilow prevenmrs on�he cansumtr's scrvice and/or at plumhing fixtures.
<br /> (2) Thc wnsumer ag¢a[o instull all back0o�v prcvcntion asscm6lics t qucstcd b}•thc MWD,and to mainlain�hosc bacAflow prevcntion assem6liu in good
<br /> working ordec The azsemblies shall be oCa typo,six and mnke appmved 6y tlie MVJD wd Ihe\Vashington State Departmrnt of Heallh Authorit}�. The
<br /> azumblics shall bc insmlled in accordancc with all standards csta6lishcd hp thc MWD.
<br /> (3) Thc water mctcr will not bc insLilled until a water usc survcy has becn su6mittcd hy Ihc applicant und Ihc Districls Cmss Connwtion Centrol Spccialist has
<br /> determined if ILe cnstomer will reed to inslall a backtlow preventu an Ihe cusmmer's side of Ihe rt;emr.
<br /> (4) That Ihe cost of any ezlension of Uic waler scrvicq renewal,replacemrnt or repair m reach and serve the proper[y descri6ed shall be bomc hy mysclf or
<br /> usigns as owner(s)of thc prcmiscs. '
<br /> (5) Thnt aIl pipes,water mcasuring devices aud o�her wnncotion equipment upstrenm fmm lhe meter shall,aRer Iheir installation,be a�iJ becnm:the propcny nf
<br /> Ote MWD,subject to nll ia rcFulations pertaining tu waler service.
<br /> (G) That alicr inslailation,i(mctcr or melcr boz and nppurtenanccs are huned or dumeged,Ihc owner,will be hcld responsible and charged(or same.
<br /> p) 7 hnt Oic M WD,iLs o�cers and agenls,shall havc Ihc riFht of ingrcss and eg¢ss ro go upon Ihc prcmiscs and propeny describcd hcrcin for thc purpose of
<br /> inspeclion,tonnecting or diswnnecling Ihe service or for such oWer purposes as lhe serv¢e may require. It is nlso undersrood during ihe lime that any o(
<br /> thc water mains may hr,out of scrvice by reason of any emergency or improvemenis authoriicd by the M WD,in any sueel or other location in uhich they
<br /> ma}'have been laid,�he MWD x�ill nof 6e required lo fumish waler during�he progress af such impmvements�n any consumer q�hose suppl}'may tlms be
<br /> cut off,or bc liablc for any damagcs for iLs failurc to do sa.
<br /> (hl Tlmt tl�c M Wll shall havc Os right to chnngc Ihc rates at any timc by Resolutioq to icmparuily discontinue Ihe scrvire to cunsumcrs,and to install llic
<br /> m:ter(s)lo¢gis�cr O�c waler wnsumed. The M1VD shall nat bc held liable for damage by water orother eause resulting fmm de(ective plumbin@ or
<br /> applianccs inttallcd hy ihc owncr or occu�ant on Ihc prcmises supplics with watcr,and Ih:faet lhat aecn6 of Ihc MWD may havc inspccled Ihc plumbir;
<br /> and applianccs shall not bc plcaJ az a basis for rccovcq�in euc oCdamaec u afo¢said if We supply nf watcr shall fail or bc inlertuptcd by reason of
<br /> accid:nt,low pmssure or other cause whatsoever,We MWD shall not bc held 1ia61e for damages nor shall su,h failure or interrupoon for any rtasonable timc
<br /> 6:hcld Io ronstiWtc a brcach of conlracl on Ihc part of Wc MWD or in any wny¢licvc lhc consumcr,N�hclhcr tcnant or o�mcr,from perfortning�hc
<br /> o6ligatian of such IcnanPs or owner's contracL R'ater shall be used 6y applicant only on tlm premises described herein. A ne�e application thall he�Ied
<br /> should water bc dcsircd for athu p¢miscs alWnugh locnted on land dcscribcd hcrcin.
<br /> � 1'7)\'' 'n,o�u,�nm'D rccammcnJs installnliun of n pressurc rcgulalin�rnlvc. Applicant acl;nmrlcJres informntinn as to lhc rccummcndatinn and
<br /> - -'-�,\assumcs full respnnsi611i�y for instaliin�nr failing IO IIItI9II 8�IfT550fC fCF11IJI10�\'BIYf UO III[1Y8IC�5�'SICRI�O'If0((C�II GORI III(�'II
<br /> � � ��I�LSSOfQ � �!���.
<br /> - �. (I(I) !The�1\5'U u(iliics checA vah�es al ihe meier�n prevent rcaler returning In lhe I)istricts mains. 7'he 11f15'D recommends installotion ufa Ihermnl
<br /> �-� espansian tank to prcrent cscessivc pressurc 6ui1J-up causcd Lr the wa�cn c�a�er. Applicant ncknoe�leJFes informulion as�n lhe recommendutinn
<br /> and assumes fuli responsiLili�y tnr installin�ur failing In install u tl�ermal czpansion lanl:. IhT.
<br /> � /�. . .1 l i � I �. / -�i` �
<br /> SHIt\ICGADDRESS: I —_r�_� �I ' �. i. .:l '� i� . LOTNO.: L 6LOCK'
<br /> CI"I'}'/S'fATFJZIP: �'- C'.1' �. i� � PLATNAME't �\ � � 1�....i '..:`\ -�':_!�.� LI
<br /> ONNGR'SNAME: L-�-' ' I�r'�Il '� LL•GALDFSCRIPYION: �O� "�-�� I+'�2- — �I"�'�r7
<br /> ONNER'S ADURGSS: ��I � �` L.S�S ��'i'��..c.l i�. L..."'
<br /> CITS;'S7'ATGJZIP:_ _: `.t'- ',, _ ��� L''� 6LDGPGRMITISSl1ED�Y: �--. ;�-�� (y._-(�'�-- -
<br /> 'Ihe prcmiscs arc m 6c uscd as a T � � MPORMA7'ION LLTTGR GIVEN: �
<br /> 5�R V ICE Tl'PG� C!IARGF.S
<br /> Ue�-cluperinslallcd ,/ (1)ScrviccinstnllntionB�.wnnretionchargc S �` �� • '�—'
<br /> Dislrict Inslalled: �� (2)General Pacilities connection charge 3 �� ��-' • ,C�
<br /> District Instail:d PuWrc� (3)O�hcr S
<br /> Toml amount rcccivcJ���ith application S ��<< � � • �'�`
<br /> 1'I'IS UNDIiRSTOOD that Ihis Applicatian,allhough signed,shall not be binding upon th=�tUI:11.TG0�1'ATER DISIRICT until oppmved by Uic DISTRICf.
<br /> _ �
<br /> 1,lhc undcrsigncd,o��ncr(nr rcprescntalicc)otthc propcny dcscribcd abovc,do hcrcby mal:c application for installation of a ' �� -inch diwnctcr��atc:��,upply
<br /> scrvicc conn�tio�including appunCnanccs,and all ncccss{��labnr t my'cxpcnscs.
<br /> Ualcd Ihis �� � J:ry of ! �' ):. -/ � '�'-�.�� . j] {}-�
<br /> � 3.patJ
<br /> APPLICANT'S'SIGNATUR[: -
<br /> ApplicanCsNamc/plcazcprinl): � �� -�' ._. .-', . ` � � � p/q\i n q ' - --
<br /> � . � - I�.:'�f N.0 , .I� /
<br /> ApplicanCs Address&Phonr Numbcr �- " - " �=C � � ' �' ��� �
<br /> 111' i TF 'r'^' -
<br /> X ��y � I_e �.:.._ � '
<br /> - CROSSCONNECTIONCONTROLSUA1MARl'ASS[SSMENTBACf:FLON'REQUIRED?_(�YES ' \ NO / �7 " """•�•
<br /> .. "I�ypcofUcvicc: Siz:olDtvice CCSlnilials: ( . ',^�-- Date:� �/Z• /
<br /> APPROVED: IUIilCPEO�1'ATER UISTRICT /y� �
<br /> �3>'� ���� Datc: %T// Z`�'�� Issucd Dy: -�`
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