|
. `"'....-. ,�—.—.—.., .- , .-i.�-_..
<br />�
<br />v
<br />MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />Meter Size: �/� Servicc Address: �;- ) �� �� ,i� � ±�' �% � "< � " � J
<br />NumberofUnits: � �
<br />�teter will be used for (check all ihat apply): V Domestic Irrigation Fire Service
<br />Acct. No.: _��� I
<br />ns�aa�� y
<br />Fire L�ne
<br />1 hereby apply for water service and agrce to be govemed, in accordance with the rcsolulions, rules anJ rcgulations of the MUKIL'!60 WATC:R
<br />DISTRICT (MWD) pertaining to wa�cr scrvicc, nmv on c�rcaftcr in c0ect. Thc undcrsigncd as owncr or rcprescntalive of thc hcrcin-describcd
<br />prcmises hcrcby agrccs as follows:
<br />(I) The consumer agrecs to install, ope�ate and meintain nt nll times, ihcir plumbing system in camplianco with the curteN edition of �ha Unifofm Plumbing
<br />Code az it penains to �he prcvention of contamination, and prouctian Gom thefmal expansion due to n closed system thnt could acur with the p¢sent or
<br />Polurc ins�allalion o(backilow pnvcntcrs on Ihc consumer's scrvicc anNor at plumbing fixlura.
<br />(2) The consumer agrces to install all 6ackllow pmvention acsemblics requesied by ihe T1WD, and �o maintain those backilow provention assanblics in good
<br />e�orking ordec The xssemblics shall be of a qPe, size and meke approved by �he M\VU and �he \Vachington State Department of Hoahh Authoriry. The
<br />rtsscmblics shall bc insiallcJ in nccurdancc wilh all slanJards cstahlishcd by ihc MWI).
<br />(3) 7Lc watcr mater wili not bc installcd until a watcr usc survcy hu bccn submittcd hy thc applicant and ihc Districis Cross Conncction Control Spccialist hac
<br />dekrmined if �he customer will necd tu install a back0ow preventer on die cus�omer's side of the meter.
<br />(4) l7iat �hc wst o(any cztcnsion of Ihc �valcr scn�icc, rcncwai, rcplaccmcnl or rcpair lo rcach end smc ihc pmperty dcscribcd shall be bomc by mysclf or
<br />acsigns az oa�ncr(s) of thc p�cmiscs.
<br />(5) Thal all pipcs, watcr mc:uuring Jcviccs anJ othcr conncolion cquipmcnt upstream from �hc mctcr shall, nllcr �hcir ins�allotion, bc :md bccomc thc properry o
<br />Wc MWD, subjcct lo all iLs rcgulmions pcnaining to watcr scrvicc.
<br />(G) Thet allcr installalion, if mcicr or mctcr 6ox anJ appuncnanccs wc buricd or dnmaged, thc owncr, will 6c heid responsiblc anJ char6cd fo� samc.
<br />(7) lhat Ihe MWD, ils o0icers and agenla, shnll havc thc righl of ingrus anJ cgress lo go upon �hc prcmiscs xnd p�opcny dcscribcd hcrein for ihe purposc of
<br />inspeciion, connec�ing or Jisconnecting the sen�i�c m for such other pumoses az ihe service may require. It is aiso unJerstood during �he �ime ihet anY of
<br />ihc watcr mains may be out of scrvicc by rc;aon of any cmcrgency or improvcmcnts authorixcd by the �1WD, in any slrcet or oWer locatiun in w�hich thcy
<br />moy havc bccn laid, ihc MWD will not bc rcyuircd to (umish �entcr Juring �hc progrcss of such improvcmcnLs �o nny consumcr whose supply mey thusbc
<br />cut olf, or bc liablc for any Jnmagcs fur its failurc to do su.
<br />(8) 17�m the MWD shall have Wc right �o chan6c dic mics at any limc by Rcsnluiion, :o kmporariiy discominue the service w consumers, and to insmll �hc
<br />mctcr(s) m rcgister thc wa�cr cunsumcd. Thc �1WD shall nut 6c hclJ liable for dwnage by H'atcror other cause resulting from dc&ctivc plumbing or
<br />applienees installed 6y the oener or occupant on �he prcmises supplies w'ith water, end �he (ac� that agen�s of Ihe MWD may have inspected the plumbing
<br />nnd applianccs shnll not bc plcaJ az a basis for « coccry in cazc of damagc az aforcsaiJ. If �hc supply of watc� shell fail or bc imcrruplcd by reaaon of
<br />accident, Inw prcssurc or othcr cause Hhets�xvcr, the MWD shall not bc held liabic (or dynegcs nor shall such faiWrc or intcrtup�ion for any i-azon�bic timc
<br />be hcld io cons�itute a brench o(canvact on the pan of the MWD or in any way relicee �he consumer, x�hether tenant or o�mer, !rom performing thc
<br />ohligation of sueh tenanCs or o�rner's comract. Wnter shall be used by applicant only un the premises described hercia A new application shall 6c fileJ
<br />should watcr be Jesired for mher prcmiscs although located on land described herliaaN uknnwled ce inform�lian as l01he recommenJdinn xnd
<br />(9) 7_hat Ihe D�WD recommenJs installolion of a pressure regulaling voh�e. App R
<br />. assumee fu ?esponsibiliry fnr Inslalling or failing 1u insull a pressure re�uloling reh'e un tM1e water syslem lo pmtecl il from high
<br />pressure. �+ �'V�i�NT•
<br />� (10) TheMWtl'utilidescheckr�ah'esalthemclerlapre��entwaterreWrningtotheDislriclsmai�.c n�`Ied eelnformuiooae�fo�Meraommendarinn
<br />expansion link lo pre�•eN cicescive pressure build-up cauud hy ihe water heaier. App��c ��.NT. � '
<br />■nd assumes full responsibiliry (or instxlling nr feiling �o install a �Acrmal czpnnsian tan ��� � .
<br />� ��<���� � .� ��'.���� ���i'i LOTNO.: i � r'��J 13IOCK'p;:�. . .
<br />SIiRVICIiADDR13S5: . — ; ,y, ., /.J
<br />CI7'Y/STATIJ7IP: , �� � �' r��<� PLATNAML. � � � �
<br />�(. ,lr,! `,t'' : S"',:� %�i�i',.�• I.EGAI.Df:SC121PTION: JJ� ..'��'i'
<br />OWNHR'SNA�fI:: �� - f�. �\
<br />- '—`' \�,-� t , _,.1 '-,' /, V l. • . l. " �
<br />O\VNI:R'S ADURGSS: -r rf;,�'; ';,1 �.�., _
<br />Cll'Y/Sl'ATV"!_IP: �.. �)�-�` t: � '�� � �.� ��ti- • �' ���''l� I3LUG P13R�11T �SSUGD IiY: � 1 a �`�t}
<br />'t7ic prcmiscs nrc lo bc uscd nt n
<br />�J�j`' INfORAtAT10N LCTTGR GIVL•N: ��
<br />..
<br />SI_RVICIi 7'YI'G:
<br />Ucvcloper Ins�allcd: ✓
<br />Dislricl Instnikd:
<br />Dislrict InslallcJ fwurc:
<br />1 R �i>. '
<br />(�) Scrvicc installation & conncc�ion chargc
<br />(2) Gcncrnl Pacililics comuclion diargc
<br />(J) Otlicr
<br />Toial nmuunt reccivcd wiih application
<br />�� ).:7-)
<br />S
<br />S .J�/��.,i<%
<br />S
<br />� , �>': • �i'JJ
<br />IT IS UWIiRSTOOD ihat ihis Applicaiion, ni�hough signcd, shnll not bc binJing u{wn thc MUKILTIiO WATER DIS7'RICT until appwrcd by thc D15TIi1C7'.
<br />%��� •inch diarncter watcr supply
<br />I, thc unJcrsigncd, o��ncr (or rcprescnm�irc) o(ihc propcny JcscribcJ obovc, du hcrcby makc npplica�ion tor installetion of a- P�II�
<br />scrvicc cmmtttion, including appuhcnviccs, nnJ nll ncccssary labocat my\ �cnscs. ,\
<br />Uatcdthis i �� dnyof . -. , _ � J . �i ,
<br />�,-- •. _��� �`� �:,-U--- FEB 1 ? 2005
<br />, .,,
<br />APPLICANTS' SIGNATURG: ` . \ �
<br />Appiic;mt's Nmnc (picacc print) \C��' � C1C �
<br />�\� .�� n.�. /AT�P �C�D�
<br />c� , It1UlOLTE t�,.., _., c., cr
<br />ApplicmiCs Address S I'honc Numbcr:
<br />CROSSCONNGCTIONCONTIiOLSUA1MARl'ASSGSSMGNTUACKPLOINRLQUIRL•D?_,p_YL'•S X� NO � ��y/`;G
<br />CCS Initials:l✓�L Uate: �� /
<br />T�pc of Dcricc: Sizc of Dcvice (' . i
<br />i�
<br />API'RO� Eli� DIU611.TE0 WATF.R DIS'1'RICP
<br />.%/��L_.—. Uate: •�. /.Y LOv
<br />ily: 'ii-
<br />;�
<br />IsSucA Uy: "=
<br />
|