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MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />Merer Siu: ��5� Service Address: ������% ��'. �f v�� �'=
<br />Number of Units:
<br />^Yvterer will bc used for (check all that apply): ✓ Domestic Irrigation ✓ Fire Servicc
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<br />Acct. No.: q► � I —
<br />r�5oaa�35
<br />Ftre Lme
<br />1 hercby apply for �eatcr scrvicc and agra to bc govcmcd, in accordancc witti thc rcsolutions, rules and regulations of the MUKIL7'EO WATHR
<br />DISTRICT (MWD) pertaining to water service, now or hercaIler in effect. 'fhe undersigned as ounor or repr.sentative of thc hercin-described
<br />prcmises hercby agrces as foilows:
<br />(i ) 'Ihe consumer aFmu m install, oporate and maintain et ell timu, Iheir plumbing system in camplianee wilh ihe curtent edition af the Uniform PIum6ing
<br />Code as it penains to U¢ prcvemion of contamination, and pmttttion Gom thertnel expension due to a closed systam �hat could occur with �he presem or
<br />Powrc instBllation af beck0oe• prcvenurs on Ihe consumer's scrvice and/or at piumbing fixmrcs.
<br />(Z) Thc consumer agreu to instail aIi 6ackllou� prcvcnGan auemM1lies rcqu:s�cd by ihe MWD, and to maintein Ihose 6ack0ow prevention azscmbiies in good
<br />H�orking ordar. The azsemblies shali be of a typc, siu end meke epproved by thc hiRD nnd Iho Wa�hington State Depertmrn� otHealth Authoriry�. 7'he �
<br />assembiies shell M1e installed in eccordance wiih ell standerds este6lished bv �he MND.
<br />(3) Thc w•etcr meter will not bc install�d uinil e wamr use survcy haz hcen suhmit�ed by thc applicant end Ihe Disuicu Cmss Conncction Convol Spccielict has
<br />Aetertnincd i(ihe customcr will nced to instuil a back0ow prcvemcr on the customcr's side of the meter.
<br />(4) 'Iha[ Ihe cost of any ex�ension of Ihe waier service, rcnewal, rcplecement or repair lo rcach end serve Ihe pmperty described shall be twme by myself or
<br />usigns ac oHner(s) olthc pRmises.
<br />(5) 7ha[ all pipu, water mcavunng devices end o�mr connection equipmom upsveam fmm tho meter shall, after Weir installation, be and becnme ihe propeny of
<br />the M WD, suhjttt to a�l its rcguletions penaining to water scrvice.
<br />(G) The[ a(tcr insmlleHon, if mctcr or mnor box and eppunenencu ere buricd or damaged, ih: ownar, will bc hcld rupon:ibie and chargcd for samc.
<br />(7) That �he MWD, i�s ofTcers and agen�c, shall have ihe right of ingrus and egress to go upan �he premises end propeny ducribed horcin for the pumose of
<br />inspce�ion, connecting or disconncc�ing ihc scrvicc or for such other purposcs az thc scrvice may rcquire. It is also unders�aod during �he time that any of
<br />�he Hater mnins may be out of scrvice by rcacon of eny emergeney or impmvemrnts eu�orimd by lhe MWD, in eny strcet or other location in which they
<br />mny hnve been laid, thc MWD will not hc rcquircd m(umish wa�cr during ihc progras of such improvomcn�s to any consumcr whose supply may thus be
<br />cut oR, or bc liablc far eny Jainaga for its failurc tn do so.
<br />(R) That �hc MN'D shall havc tfm right to changc thc rata at any timc by Ruolution, to tcmporanly discontinuc thc scrvia to consumcrs, nnd to inswll thc
<br />m:ter(s) to rcgistcr the x�aicr consumcd. The M W� shai� nat be held 1ia61c for damage by wa�cr or o�her uusc resWting from defeciivc plumbing or
<br />appiianees insinlled 6y the awner or occupant on the prcmisca suppiies with x�amr, and the (act that agenis of the MWD may have inspec�ed Om plumbing
<br />and applionccs shail nut br picad as a bn�is for mcovcry in cazc of damagc as aforesaid. If�he supply of wmor sheli tail or 6e intertupmd by rcacon of
<br />nccidrnL low� prcssurc or olher causc ahatsoover, We AfN'D shnll not bc hcld iie6le for damagcs nor shall such failure or interruption far any rca�onable time
<br />i�' tic'hcld��n constiwte n 6rcach of contrect on the part ol�hc MWD or in nny way rclicvc ihc consumor, whethcr tenent or awner, (mm perfotming the
<br />obligation of such tenant's or ouner's mntract. Water shail b: uscd by npplicant onlp on �ic premises described hcmin. A new application shail 6c filed
<br />('+ ihould x�atcr ho dcsfred for othcr prcmises ol�hough IocetEd6n land dcscrihcd horcin.
<br />p1) � 'Riat Ihr JI{VU recommcnds installalinn of a pressurc reFuld(n��9b�c. Applicanl acknowledRes inform�lioo�s lo.the rernmmend�lion �nd
<br />--- essumcs fullje,t�onsl6ility fnr inetaliinp or failing to install a pressure regulalin� rah�c an the w�ter system lo�proleot II from hiRh
<br />I prueurc. \��. I�P. .--r-�—•__�
<br />-- �(10) Thr �1N'D Jtilius check valves at ihe meter to prevent water returning tn �he Ilistric�s mairo. The �iWD iecqmmends In��ollation ofe ihermd
<br />cipansion tank lo prcvent e:cessive pressure build-up ayuscd M� Ihc waler hnmr. Applieant.uk�,prvltdRes leforma[ion as lo lhc recommendetian
<br />anJ assumes full rcaponsihilitr for installing or 6ilin� to instnll n Ihermd e:; ansian tank ,1 � I�T.�.. � '--
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<br />SGR\'ICE ADDRFSti: LOT NO.: J`
<br />� F3LOCK>
<br />CITI7STATE2IP: lr/r:, `/^�^ �, .
<br />PLATNAME: �I.�iI%%%� � 1�����x-
<br />O1tRJER'S1:AML•: %3.��r%' .!%`�'%` f�;%!O�'�i' LHGALDESCRIPTION: �%.7T•
<br />OWNGR'SAUDRE55: ..��.�.�!!rt� '{�%,r�
<br />Clfl'/STAi1;IlIP: .�:.�:��� ��.-.J�••'/:.- ii� ^� , A
<br />� I3LUG I ERMIT ISSUED DY: (�� �-�
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<br />T1ic premiscs arc ta bc uscd a� a r' INFORMATION LETTL•R GIVEN: �
<br />�1-:R\�ICe Trr�:
<br />Developer Insmllcd: ✓
<br />Uisvict Installod:
<br />Disuict Instnllcd Pulurc:
<br />, ctinacr:s• ,
<br />� (I) Scrvicc insmllation S conncc�ion charge
<br />'-.(2) Gencml Focildiu conncaion chvgc
<br />(3) Otl¢r
<br />Tomi nmount «cei��cd �rith application
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<br />IT IS UNDERSTOOD that ihis Application, nithou�li signcQ shall not bc binding upon ihe MUF:ILTGO \VATER DISTRICT until epprovcd by thc DISTRICT.
<br />1, thc undcrsigncd, o��ncr (or mprcscmatirc) of th: propcnp ducribcd nbovc, do hcrcby mnke application for instelletion of a��� -inch d' yt�en��.pter supply
<br />scn�icc conncct�q, including appuncnances, mdall nccusnfi• Inboryt my capcnscs. �1i1L
<br />Dnlcdthis �� Jayo( �-�%��-� - ;�,OI��
<br />nrrucnr�Ts•sicNnruae: ! =-�„�.,��.r APR j 3 Z�P:,
<br />AppGcant'sN;mic(plcascprinQ: � ��._J� ..V�.. � � � } .
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<br />Applicant's Addrcss & Phonc Numbcr:
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<br />�- CROSSCONNC-CTION�C9 NTROLSUMMAP.1'.4SSCS°�1�tvTf3ACI:FLON'REQUIRED? `�. 1'HS NO`�� ' �
<br />T�TcofDcvice:_1JL V�` Sizc��evice: CCSlnitiels:��\\j�\\ Datc: R� �y f
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<br />AI'!'ROYL ��j fURILTF.O\1'ATERUISTRICT \~'"
<br />B>��. �',� �� Date �/ !/aJ� iss„cdBy: �i �
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