1921 HOLLOW DALE PL 2016-01-01 MF Import

' �. MUKILTSO WATER DISTRICT MPLICATION FOR WATER � � � J�J/ v� c � Meter Size: � `/ _ Service Addrees: � � �'' " � � � Number of Umts: �/ i�wteter will be used for (check all that apply): /� Domestic Irrigation _ �� Fire Service A��. No.: _i_� � _Q 5 Fire Line 1 hercby apply for water service and egrce to bc govcmed, in accordance with the rcsolutions, rulos end rcguletions of thc MIJF:IL7'EO WATER DISTRICT (MWD) pertflining to wakr servicc, now or hereafier in c0ect. 'Il¢ undersigned az owner ar representetive of the hercin-described premises hereby flgrees as follows: (I) 'Ihc wnsumer egrces to insull, openm end mnintnin u ell tima, their plumbing system in wmplianee with the current edition o(�he Unifmm Plumbing Code ss it pertains to Iho pm�:ntion of wnweination, +�J pmmctlon from thermel expuision due to e cloud system ihet wuld occur with Ne prcscnt or (uture insWleuon of back0ow pmventers on ihe wnsumtt's urvice onNor az plumbing fixturcs. (2) The consumer ag�ees to intUll all becklloH• pmentian sssemblia rcquated by ihe MWD, end to meintain thosc backflow prtvontion assemblia in good working ordec The azsem6liu shall be of e type, sis and mako approved by the MWD md the Wsshing�em Stete Depertrnrnt of Heal�h Authoriry. The assembliu sheil be instnlled in ecwrdence with dl sunduds au6iished by the MWD. (3) The water meter will not be instelled until a water uu survry hss ban submined by the eq�piiunt and the Disviels Cro:s Connection Conwl Speciulist hac determincd ifihe customer will nad to instell e bnckflaw preventer on the cusmmer's side ottfie meter. (4) That the wst of eny extension o(�he weter service, renewel, replacanent or rcpsir to reech end serve the pro�erty ducribed shell be b.,�nc by myself or assigns u owner(s) of ihe prcmisec. (5) That ell pipes, weter mcssuring devias and o�her eonnection equipment upsVtam from the m�t�r shall, efler thei� .istellation, bc and becnme the propeny of the MWD, subject to dl its rcgulsGons pertaining in wetu servicc. (6) Thet efter insW lation, if ineter or meter 6oz anJ appunenmca ue buried or dameged, tho owncr, will be hAd responsible �nd chvgW for seme. (7) That Ihe MWD, its oRcers end agcnts, shell havc the right of ingras end egras to go upon ihe prcmises end pmperty daaibed hercin (ar Ihe pulpose of inspecGon, connecting or diuonnecting ihe serviee or for suth other pwposa ss tho smia mey rcquin:. It is dso understood during the time thet eny of the wekr meins mey 6e aut of servia by rcason of eny emergency or impravements eu�horind 6y the MWD, in eny strat or othtt locetion in which ihey mey heve IKen leid, Itie MWD will not bc requircd to fumish wrettt during ihe progress of such impmvemrn�s to eny wnsumer whose supply may Nus be cut oR, or bo lieblc for any demegs (or its feilurc �o do sa. (8) 7het �hc M WD shell heve �hc right to chengc the reta at any timo 6y Raolution, to iemporerily discontinue Ihe service w wns�uners, and w instell thc meta(s1 to register Ihe weter consumed. The M WD shall not be hcld lieblc !or demege Ay weter or other ause �esulting [rom defeetive plumbing or epplimar insW led by tho owntt or occupant on thc prcmisu supplia with water, and ttm fect ihat egrnts of the MWD mry iuve inspected tLe plumbing end appliences shell not be plesd ss a 6uis (ur rccoveq• in case of demage u eforesaid. If the supply oC weter shdl ful or be intrnupted by rcacon of accident, low pmssurc or o�her cause afiauoever, thc MWG shall not be held Iieble for demaga nor shell suah Ceilure m intrnupuon for eny �easoneble time be held m constitu�e a brtach of contnct an ihe pnn of Ihe M WD or in any wey rclieve the wnsumu, wheNer tenent or ownu, from perfortning the o6ligetion af such tenenPs or owna's canirect. Water shill bo used by applicent only on �he pmnisu dauibed haein. A new application shell be filed should weter be daircd for other prcmisa elihough locatod on lend described haein. (9) 7Lrt the MN'D raommeods Imuli�tion of a pres�ure regulaN� vilve. Appliunl �tlwowledge+ioform�tion �s to the rcrnmmeod�lion and r1 �uuna full rppondbflih• for InsuilinR ar f�ilinF lo insull � prcnurc reRul�HoR v�lve on Ihc w�ter ryflem lo proteat it trom high presmrt. � � IP71'. �-' p0) The MWD u81im edeck v�lvu �t the meter tn prevent w�ter re�urninF ro the Districis mains. The M11WD recammmda imhllitlon of � thermil apamion t�el• lo prevent escaaire preuurc build-up amed by the wtler heater. Appliunt acWowledga Inform�Haa af to t6e reeommendation �nd avuma full rnponsibiliq' for inrtalliaF or f�ilinF �o inslall � tAermal c=pansion link `'� I�T. SGRVICGADDRESS �/� � l"��I'��`� "-�-L�� ' LOTNO.: � BIAC �U D�V I J�/CTI- I.� 7b' �'"'�L�� Tj �_ Z- CRY/STA7FILIP: �_T "-I pI,ATNAME: r�i��C' t � I . OWNLR'S NAME: � � � - � �'� k � � (� LEGN. DESCRIPTION: U � r' =-� � � � r^ �� C� owNea•s nnnKess: l y!�I /f'� �u% a i� S 1'1 w1�� r� j 11 u � LT L ciTwsTnrerzir C V� %[ i! c-�'n y'� �; v DLDG PERMIT ISSUED BY: �-��''�� ' \"�"• �`-1`1'1''� ✓ The pmmisa ve to be uxd aa SF.RVICETYI'C� � Davclaper tnsWlca: District Instalicd: Dis�rict InstellcJ Futurc: INFORMATIONLET7ERGIVEN: ' CI IARGFS: (I) Service installetion S eannection chugo (2) Genoml Faeilities wnnedion ehargo (3) Olhcr Totel amount rcceired with epplication S 35 I �' S �V� S S -�� • tT IS IJI:DERSTOOD �het �his Applica�ion, although sipmd, shnll not be binding upon Ihe MUF:IL7'EO WATER DISTRICT until ppproved by the DISIRICT. I� I, thc undersiEmod, oxncr (or rcpresrnintiro) af the propcny dcscribed abo��e, do he¢by make eppliwion for installation oCe�-inch diemeter waur supply sen�ice conRr{tion,�including ep ur cianar, ond eli necesj�n� In6arqt my ezpenuc. Uatcdlhis dN! da)•of �-.'J!'�ll'�i �� i1 ��-J.�.. nrr�icnrrrs•sicHn�rutt�: _._-..=;�- c.-,� Applican�'s Nemc (Pleesc piint): � ' ' : . "n � �_ r„ ! ;' v ! _ • .�i., +✓ C N Applicent'sAddress3PhoneNumbce , •' -� = �-^w `_: 11 rJ �� . {r �� ._ ` 7y I �- � CROSS CO�IECfION COMROL SUMMARI' ASSFSSMENf BACF:FLON' REQUIRED? YES h NO�,/ . T�7xofDcvia: SiuofDevice: CCSlnitieLrj�,.i� Deta H� � �i APPROVk: MUKILTEON'ATERUISTRICI' [l>', i"` i � Date:? ✓ �`O,�J9' PAID FEB ` 1 p MVWVD Iuued By: �