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` �� � MUKILTEO WATER DISTRICT
<br />APPLICATION FOR R'ATER
<br />� , ^l, _ / r-
<br />Meter Size: `��� Service Address: �`� ���� �! - l^
<br />Number of Uni�
<br />��Ivleter will bc used for (check all that apply): ✓ Domestic Irrigation �Fire Service
<br />�
<br />Acct. No.: Q � �� �
<br />n�oa3 i3� i
<br />Firc Line
<br />1 hcrcby apply for watcr servicc and agrce m bc govemcd, in accordance with thc resolutions, rules end rcguletions of the MUKILTEO WATER
<br />DISTItICT (MN'D) penaining to water service, no��• or hereaIler in elfect. The undersigned es ownor or rcpresentati��e of the hercin-described
<br />prcmises hcreby agrces as follows:
<br />(I ) The consumer eg¢cs m instali, operam and meintain at nll timu, their plumbing systcm in complience wiih ihe wrrent edition of Uie UniPortn Plumbing
<br />Codc ns it penains w ihc prcvrniion of contamination, and protcction Gom �hertnni cxpension due to a closed system thet couid c:cur with �he present or
<br />fumre installauon of backllow prcrcnters on ihe wnsumePs servicc and/or at plumbing firztures. �°
<br />(2) The consumer agrecs to install aIl bad:llow prcvention acsembliu rcquuted 6y �he MKD, and to maintnin Ihose backtlow prevention acsemblies in good
<br />xnd:ing order. Thc asscmblies shall be nf a t}pc, sim end meke epproved by the MWD and thc Wachington S�ete Deparunent af Healih Authority. Tha
<br />uscmblies shall be ins�alled in ecwrdancc wi�h a�l stenderds uwblished by ihe MWD. �
<br />(3) 7'h� wuter meter wili not be installed until o�aaur use survey hac been submined by the applicant and the Districts Cross Connection Conuol Specialist has
<br />dctcrmincd if�ho customcr will necd to insmll a backllow prwcnmr on �he astomar's sidc af thc metcr.
<br />(4) That Ihe cost of any eztonsion of lhc w�al[r servico, rcncwal, tepleccmrnt or repair lo rcnch end srnc (hc properry• dcsctibed Shall bc Iwmc by mysolf or
<br />assigns a; oW�ncr(s) of ihc premiscs.
<br />(5) That all pipes, wemr mcasuring dcriccs end other eonnec�ion equipmcnt upsvenm from ihe memr shail, nilcr ihcir insiallation, bo end becnme the propcny o!
<br />the I.1WD, subjat to all ils reguietions pcnaining to w•amr scrvice.
<br />(6) That afmr instelletion, if mc�er or meter baa anJ appuncnances are buried or damagcd, ihe oxner, will be hcld responsible nnd eharged !or samc.
<br />(7) That We �1WD, its oRcers nnd agcn�s, shall heve thc right of ingreu and egressyo go upon �he pramisu and praperty ducribed hercin for the purpose of
<br />- � inspe.lion, connecting or disconnating thc scrvice or for such other puqwses as thc service may rcquirc. It is also understood during the timc ihat any of
<br />�hc Hatcr mains may bc out of scrvice by rcason of any cmergcncy or impmvcmcn�s emhorimd by �he MWD, in any sdeet or other location in which thoy
<br />map havc bccn Iaid, Ihc MN'U aill nm bc mquired lo fumish water during thc pmprcss of such improvemonts to nny consumcr whose supply may thus be
<br />cut olf, on c� liablc for nny damagcs for i�s failurc io do so.
<br />(8) That thc MND shall havc ihe right m change thc roms at any timc by Ruolution, m temporarily diswntinuc thc service m wnsumers, end ro install thc
<br />meter(s) �o «gis�cr �hc o�atcr consumed. The MWD shall not bc heid Ii¢ble for damegc by water or other cause rcsulting fmm detectivc plumbing or
<br />appliances instnlled by ihc oHneror occupant on tlic premisu supplics e�ith water, and the fact Ihat agents of the MWD may have inspected �he plum6ing
<br />and applinnccs shall not be plead az a basis (or rccovc�• in cnsc of damagc u afarcseid. If ihe suppl}• of water shell fail or bc intertupted by reazon of
<br />eccldcnt, low erasurc or othor causc whanocvcr, the MWD shnll not be hald 1ie61e (or demaga nor shall such failure or intcrtuptlon for eny masonable �in�.c
<br />bc Acld m cpn:thmc a brcach of convact on ihc pan of �he MWD or-in any way rc�jevc thc consumcr, whe�her tenent ar oWncr�from performing thc
<br />obligation of such tenanCs or m�ncr's cnntract. \I'atcr shall Ac uscd b�;'eppMcenl ooly on the premises described hercin. A neu' a�plirationshall be filcd
<br />slmuld ���ater,he Jesired (or other pmmises oithough locatod on Innd described herein. .•-' �
<br />(9) Thit the�TjN'y:rccnmmends inslallutinn uf u pressurc repulatinF r�h'a Appliunf �cAnorvledges in(ormation is fo Ihe rcpommend4lion end
<br />- �ssumcs full resolmsibilitg fnr inslalling or fniling ro install e prexsurc rcFW�ting valve on Ihe water ryriem to protect il from high
<br />^ pressure.' \-�`� InT.
<br />���-�) QO) Th� 1NR'� utilizes check vulres at �he meter tu prcrent w�amr rc�urning tn the Districts mains. The DiWD «commends inetallation of a thermd
<br />espansian unk to prevent execssi�r pressure 6uiIJ-np caused bc the water heater. Applicant olAinwledFes informution is to the recammendation
<br />and assumcs fnll respansibilih� fnr inslallinF or failin� In install a Ihermal cxp�n5ian t�nl;. �l�/ INT.
<br />I"��% 7%'7".^-/1 e�,y LOi NO.: `�
<br />SERVICE ADDRESS: � � � � DLOCK: •
<br />CIl'Y/STA7FILIP: Cl/�"�:�i` ✓/".• PLATNAME: �'-�'J;/,"�.�, �-•n:•• •L
<br />OWNC•R'SNM1E: '�?'•!r.^''`�!�-�� ����:%�:'�%'. � LEGALDGSCRIPTION: �%��'.
<br />OWNER'S ADDRGSS: � �f � <-' ��t� ��y %�
<br />CITY/STA7'FILIP: �'• r�=� "' ���� �% �� OLDGPERMITISSUEDI3Y: ^r'�'' ��
<br />7Lc pmmisu are to be uscd as e � r INFORMATION LGTTER GI VGN:
<br />SLR\'ICE TYPH�
<br />Dcveluper insullad: ✓
<br />Uistrict Installed:
<br />District Insinlied Fumrc:
<br />CI IARGES
<br />(I ) Scn•icc instnllntion S wnnectian chargc
<br />(2) �c:�cral facilities cunnec�ion chargo
<br />(3)Othcr � .
<br />Total nmoun( rccci��cd �cith npplicetion
<br />S ^„�:J�OG�
<br />S �`>,� �.� 4.�
<br />S
<br />t a�v'��
<br />IT IS UNDLRSTOOD ihat tliis Applica�ion, nl�ou�li signcd, shall not bc binding upon thc MUF:ILTCO N'ATER DISTRICT until approved by thc D1Sii21CT.
<br />/,/
<br />1, ihe undersigned, o�mer (or rcpmcentatice) of the propeny ducrihed nbove, do hcrchr makc applica�ion for installetion af a�� r-inch diamet w t�r supply
<br />scrvicc conncclipp, including appurtctl5ncc,s �nnd nII nccusnq• lnbn�,umy expcnscs. �� 1�
<br />Ualcd Utis � day of `.� �. � � ='-� 1?
<br />APPI.ICANTS' SIGNATURG: __
<br />ApplicanPs Namc (plcasc prinQ: _
<br />ApplicanCs Addmss S Phonc Numbcr.
<br />V< _',lr.,�syi
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<br />F�,FR i 3 _uo_
<br />��.1�IiY��L��lf1�-'V �
<br />CRO55 COTRJGCTIO�v CO�TjtOL SV�1MARl' ASSGSS�ILNTl3ACf:PLON' REQUIRED? � YES N�
<br />7)pcolDccice U�-�/�' �SizcolDcvicc: CCSinitials: � y�u�� �
<br />� � i
<br />A!'PRO�'IJ� \tU1:1l.TE0 N'ATGR DIS'CRICT \__, '
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<br />0j.: �. f Da�o: 9 'f Zm�s
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<br />issued By: ��`�-'
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