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" ' MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />Metcr Siu: � Scrvice Address: 9✓�`.J�' �%� ��� ��
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<br />NumberofGnits: / - ��.=Fr
<br />�� 1�9eter will be used for (check all thal apply): � Domestic _�rtigation Fire Service
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<br />Acct. No.: GI U � y O
<br />Fire Linc
<br />1 hcreby apply for u�atcr scrvice and agrcc to be govemed, in ncwrdance with �hc rcsolutions, mles end rcgulations of thc MUKILTEO WA7'BR
<br />DIS7RICT (M WD) pertaining to water scrvice, now on c�rcaficr in cftae Thc undersigncd az owncr or repmseniative of the hcrcimdescribed
<br />premises hercby agrecs es follows:
<br />(I ) The consumer egrecs to install, operam end maintein at eil times, iheir plumbing s�5tem in wmplienec with �he curtent edition of Ihe Uni(ortn Plumbin5
<br />Code es it peneins �o the prtvention of con�emination, and prottclion Gom Ihe(meI ezpension due 1n e closW system Ihel wuld occur eilh �he presrnt or
<br />NWre installelion af beckllnw pm�cmcrs on �hc wnsumei s service enNor at plumbing fizmrts.
<br />(2) The wnsumer egrea in inslail all 6acktloe� prcveniion assembhes rtqucsted Ay Ihe MWD, end lo meintain ihose bnektlow prcvrntion assembGes in good
<br />working ordci. Thc assemblia shail b� ofa q7rc, sim and mekc approrcd by lhe MR'D and lhe Wsshington SWe Depenmrnt of Healt}i Aulhonty. Thc
<br />acsomMics shell be instellW in ecmrdance with all sWnderds established hy Ihe MWD.
<br />(3) The uater mcler will not M1c instalied until a wafer use survcy has been suhmined M1y Ihe applieane end Ihe Districts Cmss Connecfion Control Specialist haa
<br />determined if Ihe cuslomer will nttd to install e backllow prcacnter on ihe customer's side o(Ihe meter.
<br />(A) That Ihe cost of eny extension of Ihe wnter scrvice, rcnewal, teplacemrnt or repair to «ach end scrvc lhe propetty described shell be bome by mysrl(or
<br />azsigns a� oumcr(s) o(Uic prcmiscs.
<br />(5) Thut all pipcs, weta mcamring deviccs end o�hcr conncction equipmrnt upstream Gom Ihc meler shall, eIIer Iheir installetion, be and 6cu+me We propeny o!
<br />thc MN'p, su6jcct lo ail i6 rcguletions pcnaining lo watcr tcrvicc.
<br />(b) . ThaI e�cr installetion, if mctcror mcter box end eppuncnenccs erc 6uricd or damaged, the owncr, will 6e held rtsponsibie and chergcd for same.
<br />(7) Thal ihe MWD, its oRttrs end egenls, shell have �hc righl of ingress and egress to go u�wn �he premisu end property described hemin (or ihe purpuse of
<br />inspection, connecting or disconn�cung ihe sercice or fur such other putposes as the scrvice mey tequirc. h is also understead dunng the time Ihat any of
<br />�hc watcr mains mag be out nf scrvicc by rcason u(anv cmcrgency or improvcmenls authoriud hy thc MR'D, in any strcet or olher IoeaGon in which �hcy
<br />mey havc hecn �aid, Ihe MWU uill not be rcquired b fumish water during Om progress af such impmvements lo any wnsumer wfiose suppty may thus bc
<br />cu: oli, or bc liablc for any damagcs for iLs fnilurc lo do so.
<br />(R) 7hat ihc MN'D shall havc tl¢ ri�Jtl �o chengc 0¢ ratcs at any limc by Rcsolutioq to Icm�rrarily diswminuc Ihc scrvicc lo wnsumcrs, and to install thc
<br />mctcht) lo rcgislcr thc w�atcr consumcd. Thc MWU shall no� bc hcld Iiabic for damagc hy watcr or olhcr cauu resulling from dcfcclive plumbing or
<br />appliancei installed hy �he ouner m occupant on �he premises supplizs with aater, and Ihe fact Ihal agenLs of Ih: MRD may have inspecled Ihe plumhing
<br />end applianees shall nol be plend ns a b�is for tecm�en in caze of damege ac aforesaid. If Ihe supply o(weter shsll fail or be intertupted by reason uf
<br />accidcn4 imr prcssurc or ntl¢r causc whalsocrcr, Ihc tviWD shall no� hc hcld lieblc for damagu nor shail such failurc or inicrruption for eny ¢atonablc iimc
<br />be hdd �n constitme e broach of wntract on the pan of Ihe MN'D nr in eny aay rclieve Ihe contumer, whether Ienant or owner, (min per(ormlrtg Ihe
<br />obli�tionnfeych Ienant's or oenei s wntracl R'ater shall be used by applicant only on Ihe prcmises described hetein. A new upplicalion shall be fded
<br />shnuld datcr�c dcsircd fnr nthcr prcmiscs allhough localcd on IanJ dcscribcd hcrcin. .
<br />(`1) Th�t Ihe M1RY�U re<nmmenJs insullation ofa pressure regulalinC rehe. Applicant ¢knowladges infnrm�tion as to Ihe rtcnmmendation and
<br />assumcstu rlc..pnnsiFility for instdling nr fxiling In insull e prtssnrc rc�ul�lin� r�Wc on the watcr.rystem In protmt il from hiFh
<br />prexsurcJ �- InT.
<br />(10) Thr �1\YU ulilius cLeck ��alves at Ihc melcr lo prevcnl a�xlcr rclurnin� In �he Uislricts mains. The A1N'D rccommends insullqtimi of a Ihermxl
<br />, eipensitin Iank to precent tzcessire prtssure build-up auned bp Ihe w�nlen c�aler. Applican ��eknoeleJFes inform�tion as m Ihe recnmmendalion
<br />.� enJ usumcs fnll responxibilily fnrimtillin� or failing I/n �inrsull u lhcrmal e:pansion hnk I�T.
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<br />SGRVICGADDRIiSS�. _ �J- J `�1�� •. (J��• �„r,,,,. ,,.__..
<br />CITI'/STATfJLIP: C-�'^' :
<br />OWNGR'S NM1G�. J ��. ' ��
<br />OWNER'.l' ADDRISS: �-^-�
<br />CfI'Y/STATE3(J_IP: �'� �� 'u:)
<br />7Lc prcmiscs are to he used as a_
<br />5l;Ii�E TYI'G_
<br />Un�cloperinsmlied: V
<br />Uistrict Inslslicd:
<br />Districl Insiallcd PWurc:
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<br />� PLAT NAML::
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<br />L13GAL DI:SCRIPTION: f
<br />✓:_ VL
<br />ULUGPGRMI7'ISSLIGD�Y: � '�� C � V '�.
<br />INFORMATIONLETTliRGIVEN: ✓
<br />CIIAk�f 4 �. .
<br />(I ) Scrvicc installetion & conncction charge
<br />(2) Gcncral Pc:ilitics conncclion chargo
<br />(3) Othcr
<br />To1nl emount tcckcJ u�i1h appliceUon
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<br />c J�u',�-
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<br />IT Iti URUGRSTr�p that ihis Appliwlion, altlinugh signcd, shall not bc binding upon Ihc MUKILT[O 1VAT8R DISiRICT until approvcd by thc DISTRICT.
<br />1. Ihe undersigned, owner (or rcprcsentdtne) of Ihe propeny described above, dn hercby make opplication for inslallation of e / -inch diarneter W aiet supplr
<br />srrvicc connrciipn, ipcluding eppurtenanccs, nnd nll nccasnp� labor at my expcnses. �ATD
<br />Uatrd ihis =_ dey of ��_ ���,_,� :=� ` ._, � �:+_:+ �0 1
<br />APPLICANTS' SIGNATURG nA'`�
<br />Appl¢ent'sNnmclPlcaacpnnQ�._ i' C'jL-�^r! 1.�Ch��:L1.�A�Ili1Li 12._.
<br />.ApplicanCsAddressRPhoncNumM1e[ 2G��— r-�'G �-' l _�� ��'� oC ����✓�.n�iLH
<br />f�AP, 2 8 ZOOo
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<br />CROSSCOhTECilONW4TRAL5UMMARI'ASSESSMENT6ACKFLOII'IiliQU1RBD? k 1'GS NO �
<br />l�rpcofDwicc:_' L� (/I SiuofDcricc: CCSlnitiels�. ��,,.� Dntc:���l�'%��
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<br />AI'1'ItOV1:Ur i AtUi:II.Tk:OK'ATBR�ISTRICI'
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<br />I{�-. � T/'� ,�-- Datc:�� Issued 13y�.
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