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<br />. MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />, � ,_.
<br />� � .���:.) � � i.��� i _r� � �:�J'i:C'. 'r' � U
<br />Meter Siu: ' �U Servicc Address:
<br />Number of Units: � V Domestic Irzigation Firc Service
<br />'ll b d for (check all that apply):
<br />Acct. No.: �.� [
<br />nSoaaG�3
<br />Fire Line —
<br />�leter wi e use
<br />I hereby apply for water servicc and ngrce to be govemed, in acwrdance wilh the resolutions, mles and rcgulations of the MUKILTEO WATER
<br />DISTRICT (MWD) pertaining to water service, now or herwiler in effect. The undersigned as owner or representative�otthe hercin-described
<br />prcmises hercby agrces �s follo�vs:
<br />(' ) Code as it pertuinrs o the prevent,on of mntem0ination `and pro �etionrfPom �hermel ozpansion doe loce closcd sys� m that�could uc�cur wilh�the present or
<br />Poture instellation of backflow prcveniers on the consumer's scrvice anNor at plumbing fixtures.
<br />(2) T6a consumer egrces to ins�alf nll bnckflow p� siu and meke a rc9ovcd by �he MWD md tl�� Wazhi gwn State Ueparime t of HcalthSAutlh'or ryn The
<br />erorking ordcc The asscmblics shall be o( a I PP
<br />acsemM1liu shall be instelled in accordanee widi nll s�enderds esteblished by the MWD.
<br />(3) The wa�er mcur H�ill not be instelled until a watcr use survcy haa barn submincd by tlw epplicant end thc Districts Cross Conncction Conuol SI10°clf orh�
<br />dctcrmincd if �ho customer will necd to install e beck0ow prcven�cr on ihe customer's side otthe metcr.
<br />(4) That Ihe wst of any eztension o(the water service, rcnewal, replacemanl or repair to rcach end sme the pmperty ducribed shall be 6ome by mys
<br />assigns az owner(s) of thc premiscs.
<br />(5) That all pipes. wamr meacaring devices end other wnneclion equipment upslrcam from the moter shali, after thcir instellation, be and bemme �he propeny o
<br />the MWD, suMject Io all its regulalions pMaining to water scrvicc.
<br />(G) Thel after installa�ion, if ma�er or meler box and apputlenanees ere buried or damaged, the owner, will 6e held «sponsible and charged or same.
<br />(7) nspectioo1, wnn ct ng or`diuonnect ngs helservice or fogt such ogherSpurposcss'�s'1he crv ce may cquire.lta serl o understi od dunnB �e i mePhaPa�iy of
<br />may havc bccn laid, thc MWD H'ill not be reyuired to fumish watcr during �hc pro6rcss of sucN improvcmcn�s to eny consumer whose supply may thus bc
<br />�he watcr mains may be out o(scrvicc by rcason o(any emergrncy or improvcmenls authoriud by thc MWD, in eny strat ur othcr location in which � uy
<br />wt o1T, ur be Iiable for enY demuges for i�s fnilurc m do sa �o ��m orarilY Jiscon�inue �he servia to consumers, and to install the
<br />�gj That Ihe MWU shall havc Ihc righl to chon6c Ihc ralcs al eny ��mc by Rcsolulion, P
<br />meteKs) to rcgisicr Ihc watcr consumcd. The MWD shall not l+e hcld lieblc for aemage by wakr or oiher cause rcsulting from defective plumbing or
<br />appliances ins�alled 6y lhe owncr or occupant on the prcmises supplics with water, end the fect thet agen�t of ihe MWD mey have inspected thc plumbing
<br />and appliences shell not bc plead as a basis for rcwvcry in cuc of domagc as eforoseid. If ihc suppiy of weter shali feil or be intortupted by rceson of
<br />boheld lo wnsi lutc a brt ch of mm a t on hc part of ihc MWD or in y�wey c'lievc the consumcr5wh'ether lcnant or oxnerufrom {terforming �he blc time
<br />obligetion o(such IenanCs or awner's contracl. Waler shall be used by applicont only on the prcmises d�scribed hercin. A new epplication shall be filed
<br />should weur bc Jce ¢d for other p¢miscs nhhough located on land Jcscribed herein.
<br />(y� Th�Lthe D rcc mmends insull�Hon oA pressure regulati�iF vdre ApP���o^� ��k^owledges information u to the rccammcndetion �nd
<br />•ssumes f�s��ibility fnr insldling or fdling to instdl a prusurc rcgul�Nng valve an Ihe w�ter syslem ro protect fl from M1igh
<br />pressure.l� �-.INT.
<br />lic�nta kn�e`� ge�laform��foniitutl�e,reco, mmend�tion
<br />� (10) T6e M�Vh,utilius cM1eck vah'es a� �M1e meler �n prerent wa�er returnin� to lhe Distriets md�S1The MWD recommends inst�llihon of � ��rm�
<br />esp�nslon link to prevent eccessive pres�ur�c build-uR caused by the w�ler hPalee App ` 1V ..+ • �
<br />■nd �ssumes full rceponsibiliry for inslallin ur failin la instdl a Ihtrmd cz �nsion t�nk. `. , �� , � �i
<br />•i-i..i� '�/7 I.OTNO.: /-��� �J 6LOCK:/,�/.�' � ' �
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<br />SI3RVICL• AUDRISS. ` ' . � � J � �%�� ��s�
<br />�. . I'LATNAML: � '
<br />CI'1'Y/STATI•ILIP. � ' ` '� '' • � .��'G" '"
<br />!.. ,.�� ,:.j��.'r� re,%ll�l:l. LGGALUIi5CRl1'TION _ � �
<br />OWN6R'SNAMI:: • � � ' ' ;�} � .,� t � � - �
<br />�'-��y �'• : - �.�. �--- . � . . \..
<br />OWN[It'SADURBSS: �� T
<br />� � .�n„�� `,. -� t. tif�� � {:C:� ; I3I.DGPI>RMII'ISSUL•DUY: � y �
<br />\ - �\ '
<br />CITY/S'1'Al'li/LIP: � - " INPORMAI'IONI.LTTfiRGNf:N: � � I
<br />5//�
<br />Thc premiscs are to bc useJ nc a f
<br />tiFRVICL• T P r�
<br />Dcvdoperinsinlicd: �=�
<br />Disirict Ins�allcJ: ,__
<br />Dislrict Ins�allcd PuUuc: _
<br />CI{ARGI>S.
<br />(1) Scrvicc installo�ion � canncc�inn chargc
<br />(2) Gcncml 1'ncilitiu wnncction charga
<br />(J) Olhcr
<br />TMnI xmoum �eccivcd with applice�ion
<br />l�•� �
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<br />S :�wl��� •(J�%
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<br />S ;jJr.�t���(1
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<br />i9' IS UNDLkSTOOD that itis Applicniion, altliough signcd, sh�ll not bc binding u�wn dic MUKILTtiO WATL•R DISTRICT un'�� � ro'ndN �Y �� � fsWatcr supplY
<br />1, thc unJcrsigncd, o��ncr (or rcprcscNmirc) of thc propc�ty dcscribeJ abovc, do hcrcby makc applicaliun for installation o(a P�j n
<br />service connection, inciuding nppurte'yNees, nnd nll necessnry� I�bo� my expenses.
<br />DatcJ�his ��� �ayof �,�� , r-Ea 1 � ?r05
<br />;-��Vi.•. �`'1 �_1.\( ��:',f�-- .
<br />APPLICAN9'S' SIGNATURG:
<br />���.�
<br />ApplicanCsNamc(Plexseprinp:�_ � •..��.,�. ( `. C\�r3_,V � �i�!I����T�L� ���".�,..', ,. . ;,
<br />-' C L1\;�.�� ��
<br />Applicant's Address & Phonc Numbcr� _
<br />�.
<br />�,� r .NO'2 ��J
<br />CROSS CONNCCTION CONTROL SUMAIARY ASSGSSMBNT 6ACK�LOW I�QCCS nitials: - Date: ��
<br />Typc of Dcricc:
<br />Sizc of Dcvicc: �
<br />AI'PROVF.V±i�� AfURI1:i'F.O NATER UIS'I'RIC'I' 7/�/�� � r
<br />��G:%F i �� -. _ Uate:
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<br />Issucd By: ' `
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