|
MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER 9
<br />Meter Size: i' /1 Service Address: %�- %= i y a /�+ �% l Acct. No.:
<br />Number of Unit
<br />i
<br />`Meter will be used for (ched. all that apply): x Domestic Irrigation Fire Service Fire Line
<br />I hereby apply for water service and agree to be governed, in accordance with the resolutions, rules and regulations of the MUKILTEO WATER
<br />DISTRICT (MWD) pertaining to water service, now or hereafter in effect. The undersigned as owner or representative of the herein -described
<br />premises hereby agrees as follows:
<br />(1) The consumer agrees to install, operate and maintain at all times, their plumbing system in compliance with the current edition of the Uniform Plumbing
<br />Code as it pertains to the prevention of contamination, and protection from thermal expansion due to a closed system that could occur with the present or
<br />future installation of backfiow preventers on the consumer's service and/or at plumbing fixtures.
<br />(2) The consumer agrees to install all backtlow prevention assemblies requested by the MWD, and to maintain those backtlow prevention assemblies in good
<br />working order. The asscmhlies shall be of a type, size and make approved by the MWD and the Washington State Department of Health Authority. The
<br />assemblies shall be installed in accordance with all standards established by the M\VD.
<br />(3) The water meter will not be installed until a water use survey has been submitted by the applicant and the Districts Cross Connection Conuoi Specialist has
<br />determined if the customer will need to install a backtlow preventer on the customer's side of the meter.
<br />(4) That the cost of any extension of the water service, renewal, replacement or repair to reach and serve the property described shall be home by myself or
<br />assigns as owner(s) of the premises.
<br />(5) That all pipes, water measuring devices and other connection equipment upstream from the meter shall, after their installation, be and become the property of
<br />die MV D, subject to all its regulations pertaining to water service.
<br />(6) That after installation, if meter or meter box and appuncr o ices arc buried or damaged, the owner, will be held responsible and charged for same.
<br />(7) That the MWD, its affects and agents, shall have the right of ingress and egress to go upon the premises and property described herein for the purpose of
<br />inspection, connecting or disconnecting the service or for such other purposs as the service may require. It is also understood during the time that any of
<br />the water mains may he out of service by reason of any emergency or improvements authorized by the M%VD, in any street or other location in which they
<br />may have been laid, the MWD will not be required to famish water during the progress of such improvements to any consumer whose supply may thus be
<br />cut off, or be liable for any damages for its failure to do so.
<br />(S) That the MWD shall have the right to change the rates at any time by Resolution, to temporarily discontinue the service to consumers, and to install the
<br />meter(s) to register the water consumed. The MWD shall not be held liable for damage by water or other cause resulting from defective plumbing or
<br />appliances installed by the owner or occupant on the premises supplies with water, and the fact that agents of the MWD may have inspected the plumbing
<br />and appliances shall not be plead as a basis for rccovcry in case of damage as aforesaid. If the supply of water shall fail or be interrupted by reason of
<br />accident, low pressure or other cause whatsoever, the MWD shall not he held liable for damages nor shall such failure or interruption for any reasonable time
<br />be held to constitute a breach of contract on the part of the MWD or in any way relieve file consumer, whether tenant or owner, from performing the
<br />obligation of such tenant's or owner's contract. Watershall be used by applicant only on the premises described herein. A new application shall be filed
<br />i^ should water he desired for other premises although located on land described herein.
<br />( (9) That the MWD recommends installation of a pressure regulating valve. Applicant acknowledges information as to the recommendation and
<br />assumes full respnnsibility for Installing or failing to install a pressure regulating V21Ve on the water system to protect it from high
<br />pressure. '! ; IN-L
<br />0 (D1; The M\\'D utilizes check valves at the meter to prevent water returning to the Districts mains. The MWD recommends installation of a thermal
<br />expansion tank to prevent excessive pressure build-up caused by the water healer. Applicant acknowledges information as to the recommendation
<br />and assume full responsibility for installing or failing 10 install a thermal expansion tank IPT.
<br />SERVICE ADDRESS: I C%%a y' ,� %'=F %� � L ,, y' q- LOT NO.: —T BLOCS::
<br />CITY/STAT- IP: T-f'Ytr4 I) Ctt'a D'-1 PLAT NAME:
<br />{ s OWNGR'SNAME: AR7/c 4vjJ>`iryc rt'rt /7L LEGAL DESCRIPTION:
<br />OWNER'S ADDRESS: Prt /J CX
<br />CITY/STATErZIP: t= uf+ i g Lt.1I C/) Z( BLDGPERMIT ISSUEDBY: C-
<br />The premises are to be used as a `" t, . �'� 1 •i INFORMATION LETTER GIVEN: t/ '
<br />SERVICE TYPE: CHARGES:
<br />Developer Installed: P (I) Scrvice installation & connection charge S ' t•l• d. "'i
<br />District Installed: (2) General Facilities connection charge S I S f I ✓ i f :i
<br />District Installed Future: (3) Other $
<br />Total amount received with application $
<br />IT IS UNDERSTOOD that this Application, although signed, shall not he binding upon the MUKILTEO WATER DISTRICT until approved by the DISTRICT.
<br />I, the undersigned, owner (or representative) of the property described above, do hereby make application for installation of a /' -inch diameter water supply
<br />service connectionincluding appurtenances, and all neccsspry labor at my expenses.
<br />,
<br />Dated this I day of"-�;� • n• 1�..• soc",
<br />�_ f" PAID
<br />APPLICANTS' SIGNATURE: .cam_' `d/•L 1, c.,`,
<br />Applicant's Name (plane print): fl l7! f< L.r trl� *r' a�Lrl I s ,� y n �•, `l� ;, —. )
<br />Applicant's Address & Phone Number: 1/SEP 12006
<br />CROSS CONNECTION CONTROL SUMMARY ASSESSMENT BACRFLOWREQUIRED?DES ,\ NO14 I(IETER VJA7ER DISTRICT
<br />Type pfDevitt: Size of Device: CCS Initials: Date: �G �2coL
<br />i
<br />APPRO\'ED•`` LTEG \PATER DISTRICT
<br />By: %/ Date: /,P/7ZIssued By: J�
<br />U�
<br />QJ
<br />
|