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<br />' , + MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />Meter 5ize: '���� Service Address: �� �� �� �� �'� � `��lr -
<br />Nu�rber of Units: / ' /
<br />Meter will be used for (check all Ihat apply): V Domestic Irrigation Fire Service
<br />Acct. No.: G G I�, I
<br />nso aao-, ��
<br />Fire Line
<br />I hereby appiy for water service and ngrec io be govemed, in accord�+nec with thc resolulions, rules and regulations of the MUKIL7'EO WATGR
<br />DISTRICT (M WD) penaining io wntcr sen•icc, now on c�rcaftcr in cffcct. Thc undcrsigncd ns owncr or rcpresentative of thc hcrein-describcd
<br />prcmiscs hcrcby ngrccs as follows:
<br />(I) The consumcr agrtts to inslall, operete anJ maintain nt ali limcs, Ihcir plumbing system in complience �.ith the currcnt edition of thc Uni(orm Plumbing
<br />Code as il penains to ihe prcvention of comamination, and prolection Gam ihermal expansion duc lo e closed iyslem that could occur wilh �he prcsent or
<br />future installation of bnek(law preventers on ihe consumer's sarvice a�iNor at plumbing fixwres.
<br />(2) The consumer agrces lo instnll all backtiow prcvention ncsemblias requested by �he MWD, end ta mainlain thosa backflow prevention azsemblies in good
<br />working order. 77ic azsemAlics shali be of a typc, sive and make approved by the MWD and the Washington State Uepanmrnt of Hcal�h Authoriry. The
<br />assemblics shall be installed in acwrdance wiih all standords established by the MWD. '
<br />(3) 7he wa�cr me�cr will not be inslalled unlil a water use survey haz bttn submilled by the applicanl and �he Disiric6 Cross Connection Cantrol Specialist has
<br />dctermincd it�hc cusmmcr will nccd �o install o back0ow pavcntcr on ihe cusmmcr's side of the meur.
<br />(4) 17iet the cost af nny extensinn of Oie wa�er scrvice, renewal, replacemem or repair io rcach md serve �he propeny described shall be twme by myself or
<br />assigns as owncr(s) of thc prcmiscs.
<br />(5) 'Ihal nll pipes, �mter measuring devices and odicr connection equipment ups�rcam from the maur shall, alicr �mir ins�alletion, be and bttome �he property o
<br />thc MWD, subjcct lo nll its Icgulalinns pcnaining lo walcr scrvicc.
<br />(6) lLat aller installation, if ineter or meur box and appurtenunees ere buricd or damagcJ, ihe owner, will be hold ruponsible anJ char6ed fo� same.
<br />(7) That Ihe MWD, iu o(ficers anJ agrnts, shell have ihe right of ingress and egmcs ro go upon ihe premises and propeny described harcin for the purpose a(
<br />inspeaion, connecting or disconnecling Ihe service or (or such olher pumoses as �he sen�ice may require. It is nlso understood during �he time Ihat any of
<br />thc walcr mains m�y bc out of srnicc by rcason n(any cmcrgrncy or impro��emen�t awhoriud 6y �he MWD, in any strccl or othcr lowtion in ahirh �hey
<br />moy havc M1ccn laid, lhc MWU will not be rcquircJ to fumish walcr during �hc progres; of such improvcmcn�s lo eny consumcr whose supply may thus be
<br />cul oR, or be Iiabie for any damagcs (ur i�s failurc �o do so.
<br />(R) TlieUhe MWD shall hnve ihe �ight to change Ihe mles at any time by Nesolution, lo iemporarily discoNinue lhe servite to consumers, and to install ihe
<br />mcicr(s) io rc6isicr �hc aatcr consumcd. llic MWD shall not bc hcld liablc for damagc by watcr or othar cause ruulting fmm deftttive plum6ing or
<br />npplianca installed by �he owncr or occupanl on the premises supplies e�i0i water, and the (acl that A6�n�t oCthe MWD mxy have inspcckd itie plumbing
<br />and appliencu shali not be plcad az a bazis for recovery in case of damege u efuresaiJ. If ihe supply of wa�cr shall fail or be inicrtupicdby mason of
<br />accidrnt, low prcssurc or othcr causc whelsocrcr, thc MWD shnll mt bc hcld IiaM1lc for.d'em�6a'nor shall such feilum or intem�ption for any « asonablc limc
<br />be hcld to cons�itii�e a brcach o(conirazl on the part of Uic MWD or in nny H'ny rclieve �he cmisumer, whether ienant or owner, (rom �erforming �he
<br />obligalion of such tniant's or owner's comract. Water shall be useJ by applicant only on �he pmmises described herein. A new application shall be filed
<br />should wntcr bc JcsircJ fur othcr prcmiscs ahhough locatcd on I.�nJ dcscribcd hercin.
<br />(9) 'lhal lhe MWD r5commends installntinn ah preuure reRulating v�lve Applicanl acknowledges informalion �s to Ihe recommend�tian And
<br />assumcs fuLl�i�ipoosibfliq� fnr installin� or failing in install a prcssnre ragul�ting ��alve an the water systcm ta protal it trom high
<br />pressure � IN7'•
<br />'(10) The 111WD utllius check rnh�rs nl thc mcler lo prerent e�ater rdurning ln Ihe Uislricle maim. The 11M'D rccommend� install�tion af a therm�l
<br />expansion lank to prevcm ezcessice pressure Auild-up caused by �he water heater. ApP������ 1SkSowledgea inform�tion u to the recommenduion
<br />and �ssumes full rcsponsibilily for installinF or 4iling lo ins�ill a Ihermal c:pansion unk. � �NT•
<br />) � �y)'1 �'�I'1..�- IATNO.: OI.00K:
<br />SIiRVICL• ADDRIiSS: ��� � � �/" � � �'., �.,. . �! ;! .Y,� ` '
<br />– � '���-' �j PI.AI'NM1G: ' � —
<br />ciTvis rn� uzir: '-- %. _ . —.--- 3 � �.
<br />`.. �: / � � ' j' r�; ' i �7l?, ' ± .% I.GGAL DGSCRIPTION: ' �
<br />ONNI:Ii'S NAMIi �- ,
<br />OR'NIIIL'S ADURFSS: : i. �' /-''"� �' 'l� � _ „ : . ' `f � _ -
<br />� , '� '.' , _ �� �.� J>� BI_UG PI:RMIT ISSUGD UY: � . �, � .
<br />CIl'Y/STA'1'1�!_IP: :�)' '�,.� `� —
<br />1Lc prcmiscs nrc �o bc uscJ as a •.J�/C INPORMATION LGTTGR GIVL•N: ---
<br />sravicr•'rvrr:
<br />�
<br />Dcvcloper InslallcJ: ��
<br />Districl InsiailcJ:
<br />Dislricl Installcd 1'ulum: _
<br />I A GPS'
<br />(I) Scrcice instailaiion & conncction cha�ge
<br />(2) Gcncml I :�cililics connec�ion chargc
<br />(3) O�hcr
<br />Tolnl amount rccci�'cd wilh application
<br />S 33g. � �
<br />•. � �� J -1 i
<br />S
<br />a �' ���
<br />I7' IS UNU[RSTOOD that �his Application, ahhough signcJ, shall nol bc binding upon thc MUKILTIA WATLR DISTRICT uni' approved hy tP�ID c��.
<br />i, �he miJcrsigncJ, owncr (or rcprcscnla�ive) uf tlm propcny describcJ a6o��c, du hcrcby meke app���A�ion (or insmllation of n��/� •inch diamcter wa�cr suppty
<br />scrvicc conncclig�, incluJing appimcn�nccs, qnJ all ncccssMq��bo�qL�ny cxpcnscs. A I R 1 3 L�.i U J
<br />Da�cd Ihis �.0 day of
<br />APPLICAN'fS'SIGNATUIiG: �-� �> �� 1"'�1''��"'' �IUKILTE(
<br />����_��_ � � , ;, � _,:�.:c r •,, .
<br />Applicant'sNvnc(plcucprim): – .c' ; 5•.�`• 5�' �
<br />�'.,�. .'�'�t �'ti::' t_��. S�r�.:V.��`i' '-1�1.
<br />Applicmu's AdJress & Phonc Nnmbcr. �.
<br />CROSS CONNGCI'ION F������KY �SSGSSM[NT UACKFLO�\' RL 'IRGU? Y� "` x`L;_,. �l�/ //i5
<br />Typc of Dcrica Sizc of Ucvicc �CCS Initials: -.�– Date.
<br />AI'I'ItOVED:/ �1G61I.TE0 N'ATF:R DIS'PRICT �� "~
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<br />��(t Da�c �1�//i 70J �
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<br />Issucd I37' ���
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