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"' MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />Meter Size: '3 J Service Address:
<br />�i���� �%?r,y�?. ;,ii,
<br />Number of Unit�
<br />�`�vicrer will be used for (check all that apply): ✓ Domestic
<br />Irrigation
<br />S
<br />Acct. No.: 4 I 13
<br />Fire Service ��� a3o�5 V'
<br />1 hcreby apply for watcr scrvicc and agrcc m be govcmcd, in accordancc with thc resolutioas, rules and rcgulations of the MUKILTEO WATER
<br />DISTRICT (MWD) pcnaining io watcr scrvice, now on c�reaflcr in eCfcct. Thc undcrsigned es owner or rcprcsentative of the hercin-described
<br />premises hereby agrces az follows:
<br />(I ) Thc consumer agrcu to inslall, operetc and maintain et eII timcs, ihcir plumbing system in compliancc �rith the curtent edition ofihc Unifortn Plumbing
<br />Code ac it prnains to th: prevemion atconteminazion, end protection fmm thertnel expension due to a closod s}skm that could ocwr with ihe pasrnt or
<br />(uture insullation of beckllow pRvrnters on ihe wnsumer's service and/or at plumbing fixtures.
<br />(2) Tho consumer agrcu m instail ail beekflow prcvontion accemblies requuted by the MR'D, and to main�ein ihose becktlow prc�•ention sssembliu in good
<br />wvrking ordec The assemhlies shell bc o!a t}7rc, sim and meke appmvcd hy thc MWD and �he 1Vuhington State Depenmrnt of Health Authorip�. 1'he
<br />asscmblics shail bc insmllcd in accordance w�ith ell s�enderds uteblished by �he MWD.
<br />(J) The wamr me�cr w•ill not be instelicd until a waler use survcy hac been su6mined bp the nppiicant and ihe Disvieis Cro�s Connection Convol Speciaiist hac
<br />dcle'mined if Wo cusiomcr wili need lo insmll a backtloa prcventor on ihc customcr's sidc oClhc meter.
<br />(4) 'Ihat �he cos� o(any eztension ofthc H�atcr scrvice, rcncwal, rcplacemrnt or rcpair to rcach end srnc thc properTy dacribed shell be bomc by myscltor
<br />astigus az awnar(s) of Ihc prcmi:es,
<br />(5) Tha[ all pipcs, watar mcasuring dorices and other connection equipmrnt upstrcem (rom Ua meter shall, afler lhcir installation, bc and bccnme thc pmpeny of
<br />Wc MWD, suhjat m ell it� rcgulations pcnaining to wattr scrvicc.
<br />(6) That a(lor instelimion, i(mat�r or meter box end eppunenencos ue 6uricd or demaged, the oHner, will bc hald rupansible and charged for same.
<br />(7) 'Ihe[ ihc MWD, i�s oRccrs and ngcnts, shell have the right of ingrcss end egrcss a go upon iho prcmisas and pmpeny described herein far the purpose of
<br />inspectioq wnnecting or disconnecting the service or (or such other pur�wses aa Ihe service may requira It is also understood during �ho time ihet any of
<br />the waler meins may be ow of scrvice by reason �f any emergrncy or improvcments authoriud by the MN'D, in any street or other location in which thcc
<br />ma}� havc bccn laid, ihc MWD will not 6c rcquircd �o fumish watcr during We progress of such improvcments w any consumer e•hose supply may thus bc
<br />cut olf, or �e Iiablc (or eny damagcs for i�s failum to do so.
<br />(8) That thc MN'D shall hmr Oic right m chanpc the retcs at ony iimc by Rcsolution, to �emporarily discontinuc �hc scrviu to wnsumers, end to insisll ihc
<br />mct_r(s) m rcgistcr lhc w•aicr consumed. The MWD shall not be hcld liablc for demagc by wmcr or othcr causc rosulting from dekctive plumbing or
<br />oppliances instalicd bp �he aener or occupant on �he prcmises suppliu with e•akr, and thc tact Ihat egcn�s of Ihc MWD mey have inspancd the plumbing
<br />and applianecs shall not be plead as e buis for recorcry in cazc of damegc az afomsaid. ICthc supply of wetcr shall Gil or bc interrupted 6y rcazon o(
<br />accidrn4 ��w� p�essurc or o�her cause aha�coever, the MN'D shall not be held 1ia61e (or damnges nor shnll such failurc or intertuptiertfor any rcaconab�c timc
<br />be'IiCld inzon�Utum a brcach of comract on �he part of �he A1WD(6Fjn en � wey�feliove �he consumer, whether tenant or owner, (ro � g Ihc
<br />ohllgation oTsuch tenont's or ouner's contrazt Water shall b: uscd-b}RA�litud aniy an the prcmises ducribed hereia A� app1iation shall 6c filed
<br />should w�ater 6c daircd for mhcr pmmiscs aithough locatcd on land Jur,rihed herein. .._ .
<br />(9) ThH�IhrMWB•reenmmends installutinn nfa pressurc reFulating vohro. Applinnt icknnwledges inform�tfon as to lhe recommend�tian �nd
<br />■ssumcs full,�esyonsibililr for InsfallinF nr failing m install � pressure rcgW�ting raWc on the water s��stem to protect It from high
<br />preseuu._>a"-iN C`
<br />(10) The �iWD ufilins chrck reWes al ihe mMer to pra�rnt water remrning to Ihe Uistricis m�ins. TF.eJ�1H'D recommends Insldl�tion of a thrrme!
<br />eip�nsinn tank to prevcnt ezmssive pressure huilJ-up nused 6�� thc water hutcr. Appiianl,���vlcdges Infarmation as ro thc recnmmrndninn
<br />anJ assumcs full respnnsihiliry� for installinF or fnilin� lo insmli e t6ermal e:panaion tanL J_ I�T.
<br />s�Rvicennnii�ss: �r'��� ���'�''12�
<br />�or No.: '� . nu�cr:: -
<br />CIT57STATFILIP: i•::����i, ��r :l.%"-C� PLATNAMG: ��i�•'l%�>'-! �✓��'`.''�x-
<br />ONRJER'SKAML': �� �,�� _ � r•n ,�I'��.,n�. -'� . LEGALDESCRIPTION: v�a•
<br />!l � . e � /' i�V .
<br />owrarrc�s nnn2ess: � •' � `%'" -
<br />CITI7STATL'fLll': % � ��`��� �� �� � ��'� =� DLDG PERMIT ISSUED Ul': ' �
<br />7lic remisu ac io bc uscd ac a �
<br />P WFOR�fAT10N LGTTER GIVGN:
<br />$[RVICETYPE'
<br />Ucreloper Instollcd: Y
<br />Disvict instnllcd:
<br />District Insmllad Fumm:
<br />CHARGHS �
<br />(I) Sarvice insinllation S conncc�ion chargc
<br />'� (2) Gcncral Pacilitiu conncetion chargc
<br />(3) Othcr
<br />To�ai nmount reccired wiUi nppiication
<br />S "`�i�J�l-
<br />c �.'�i��c'�?
<br />IT IS UNDii:STOOD thnt ihis Applicaiion, olthough signcd. shall not be binJing upon the �tUI:ILTEO R'ATGR DISTRICT until a prmed by thc DISTRICT.
<br />s%v P �.iD
<br />1, thc undcrsigned, nxncr (or rcpresentativc) of Ihe pmpenc dcscribed abovc, do hereby mokc nppiicntion for installation of a -inch diameter wator supply
<br />scrcice conncel n, induding appunen�nas� and all necus.v}�Jagoeat nry• eapenses.
<br />Da�cdlhis �J dayof �'�'�'P� '-'-�� � AFR 1 3 2�C7
<br />.1PPLICANTS'SIGNATURE: �J �— , `-�-s-�I�-�
<br />Applic.�nCs N:unc (plcncc print): _ �'��"'v'' ,�-�' � • �'•� .�
<br />ApplicanYsAddressSPhoncNcmbcr. c� ;7�� �)��`:'"" �-� ..+--�
<br />f,�:::::-�C !';?,:cR D;:TP,ICi
<br />1�7i- ��C, �7i.%
<br />- CROSS CONNECTION.CONTROL SUAIMARI' ASSESSM[NT DACI:PL011; REQUIRED? �YLS � N0. v�f/,i5
<br />Typc of Dcvicc Sim of Dcvice: .�� CCS Inilials: ��"'! �,--:°`Datc:
<br />,\I'i'It0\" ):�/ AfUKIL7'EO �YATGit DIS'I72ICT � • �
<br />�� v
<br />t�r: ./.j � ti"- ���`��O�j ,
<br />!7 Datc:
<br />Issuca By: '��—
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