|
111UKILTEO �1'ATGR DISTRICT �
<br /> APPLICATION FOR�VATER �
<br /> Mcter Size: '-��y Scrvice Address: � "�� " ���''t'i� �� %%� Aat.No.:_4S]_�Q �/ '
<br /> Number of Linits: O'
<br /> " `Mcter will be used for(check all that apply): �� Domestic Irrigation Fire Service Fire Line
<br /> 1 hercby apply for watcr servicc and agrcc to hc govcmed, in accordance with the resolutions,rules and rcgulations of thc MUKIL"fE01A'ATER
<br /> DIS'CIIIC'P(M\1'D)penaining to water service,now or hercafler in et7�ect. The undersigned as owner or representative of thc hercin-described
<br /> premises hcrch}�aErecs a:follows:
<br /> (I) The consumcr agrtts to install,operatc and main[ain ct all timcs,thcir plumbine sysicm in compliance�vilh G¢curtcnt cdition of Ihe Unitortn Plumbing
<br /> Codc u it pertains to tl�c prcvention of contaminalion,and pmlcction fmm Ilicrmal expansion duc to a closed systcm thut could oocur wilh ih=prcsen[or
<br /> (uWre insmllation o(6acA0ow prcvcnma on�hc consumcr's scn�icc andlor at plumbing fixlures.
<br /> (2) The consumer a�ma to insmll all bacF.tlow�preventiun assemblia mquested bp the�1R�D,and to meintain those backilok�prevention assem6lies in good
<br /> �sorkin�ordec The assemhlies shull be of a type,si�c nnd maV;c appmved by�the Mll'D and the N'ashingtnn Stat�Depanmem of Health Authoritp. Th:
<br /> asscmblics shali h:insWllcd in accorJancc wi�i all smndards cstnblishcd by Oie MWD.
<br /> (3) Thc walcr mctcr will nol bc installcd until a waicr utc survry haz becn suhmittcd by Ihc applicant and thc Dis[ricLs Cmss Conncction Canvel Spccialiri has
<br /> deicrtnined if the cusmmer will necd to ins�all a 6ackOnw'preventer on We customer's side of the meter.
<br /> (4) Tiiat thc rosl of any cxlcnsion of Ihc�smcr servicc,rcnc�eal,replacem:nl or rcpair to rcach and sme Ihe property descri6eL shall 6c 6omc by mysel(ar
<br /> usigns az oencr(s)of Ihc prcmiscs.
<br /> (5) ThtC all pipes,x�atet mtasuring dcvices and other connretion equipmcnt upstrcam fmm the metcr shall,after�heir installation,be and bccom:thc propcny of
<br /> thc M1VD,suhjert In all iLs regulatinns pcttaining tn water scrvicc.
<br /> (6j That aficr insmll3tion,if mcler or memr bm�und nppunenances are buried or damaged,the m��ner,will be h:id responsible and char@ed Cor s:une.
<br /> (7j "lhat thc MN'D,its officcrs and agcn�s,sha��havc thc right of in@ress and cgress to go upon thc prcmiacs and propcny describcd herein(or thc purposc of
<br /> inspcainn.connccting or disconnccting th:scrvicc or tur such olhcr purposcs as thc service map rcquirc. It is nlso unJeatood dunng thc time that any oC
<br /> the water mains may be uut o(scrvice by reawn olany emergenc}or impmvemen6 aWhorized by the M WP,in any svect or o:her location in which thcy
<br /> ma��hnvc been laid,the�1WD will nat bc rcquirctl to(umish wntcr during th:pmcr;ss of such improvcmcnts tu any eonsumer whose suppl}•may thus bc
<br /> cut otl�,m 6c liablc for any dumaga for i�c failure to Ao so.
<br /> (N) Thu:thc A1R'D shall havc thc right to changc thc rams al anq time by Rcsolution,to tcmporarih•discontinuc thc scrvicc tn cansumers,arid to ins[aIl the
<br /> meter(s)«i¢gister th:w�a¢r cansumed. The�715'D shall not bc hdd 1ia61c for damaee b}'u�ater or olher cause resWting from defeetive plumbing ar
<br /> applianccs iostnllcd by thc au�ncr nr occupant on thc prcmiscs supplics wilh watcr,and thc fact�hat agrn�c of ihe�:W'D m�y havc inspccmu Oic plumbing
<br /> xnd applianccs shail nol bc plcad as a hasis for rccmcn�in assc of damagc as a(arcsaid. If O�c supnly af aatcr shall(ail or b:interruptcd hy reuon of
<br /> aceid:nl,lo�+pressurc or other causc whaLsocvcr,We MWD shall no[bc hclJ liable for damaccs nor shall such failure or'Ncrtuption for any¢asnnablc Iim:
<br /> h�hcld to consiinnr a 6rcach of wnua:t on th:part of th:�4N'D or in any way rclicve Ihe consumcr,ahcthu�cnant ur ouner,fmm pcdorming!lie
<br /> nblieation of such tenanf s or o�vner's contract. Water shail be used by applicmt onl}�on the prcmises descriacd liemia A no�r application shall 6:Sled
<br /> should walcr bc dcsircJ(or othc;prcmiscs altnough IocatcJ on I.�nd J:scribed hcrcin.
<br /> (7) That�he�I\\'D rrenmmenJs inctallalion nf n pressure re�ula�ing�'nire. Applicunt ueknmeleJ,qes informnlion as lu Ihe recommnidatiun anJ �
<br /> assumes full respnnsibilily fnr installin�or fnilin�lo instull u prc¢surc rcgula�ing valve on lhe�eater sysicm to prolcct i[from hieh
<br /> , prcssnrc... IM1I�.
<br /> �. (10) Tl.r )1�1D uliliacs chccA vah�cs at�hr mcicr!u prcrcnt�rnicr r[Inrnin�(O IIIC UI$(fICIS If181f15. TIIC I�I�YD fCCO111I1LLp1I5 II15I�IIflGOt1 OId IIIff1110I
<br /> CI�lIDltilpll���L IO�1R�'f0!C%fP511Vf�I�CSSOfC IIIIIIII-ll�l CJIl5L1I IR':hC N'll[Cf�ICNtfI'. A�I�I�ICA11l3CLfI0N'IC(IFCS IIIIOff118GU0 LS fO lI1C�C[Oflllll[0�311011
<br /> nnJ assimics full responsibilih�fnr inslalling nr failin�Io install a�hcrmul cipansinn rnnk._IfiC.
<br /> SGRVICH ADDRGSS�. �^ L'/^ - ��-�����,' _ ... . LO'f NO.: — [JLOCK:_
<br /> CITI'/STATPJZIP. F�f.' ! n:-' . 1/,•r� PLATNAME: �.;�.:.'.-'^�/ - �• n ,�''r-
<br /> O\VNLR'SNAMG: � . •.-�����'�!.: `.`•�.�—T'•'' '�-. ��- . LEGALDLSCILIPTION: ' - �' '_
<br /> pR�NHR'S ADDRESS..�.. . -._.��•� i�,��I D� y�'J __
<br /> CITY/Sl'AT[O.IP'. �` �. �,��� ;, ' ���" � ���'' ' ,-� �LDGPERA7ITISSUEDDY: ` ���'r ,l
<br /> "I"hc prcmises are m hc used u a `���r' _ MPOR�tAT10N LE7TER GIVEN:
<br /> SFRVICE T1_PF.� CHARGfS:
<br /> Uevduperins�alled: �' (I)Scrviccinsinllation&eonnectioncharge 5 ��� '}il
<br /> � j,-/�-r L7,!�
<br /> Disuict Instailcd: ('_)Gcncral Pa:ilitios conncction chargc 5 -� -�`�- '
<br /> Dis�nct InstallcJ Puiurc. (3)Olhcr �
<br /> : : �j,;a �
<br /> Total mnount rcccivcd with application S=
<br /> 1'f IS UNUHCSTOOD that lhis Applicalion,although sicn:d,shall nut bc binding upon Wc MUI:ILTEO WATGR DISTRICT until nnproced by thc DISTRICT.
<br /> _ %L:
<br /> I,�hc undcrsigncd,oencr(or represcnmcivr)o(thc propcny dcscribcd nbm�c,do hcreby maAc npplication for insmllation of a -inch diamctcr x�atcr supply
<br /> sen'ic:connec�lon,incWdin�appurtcnmic:s,and ull neceuip�labof pt my eapenses.
<br /> UutcJ Ihis_ .�� day of_ ' - '� �=
<br /> N'PLICANTS'SIGNATURE � . /�� -
<br /> ��1...
<br /> Appli.viPs Namc(picasc prin0: -_ ' '- , � � "—" -- =,�
<br /> - i � , - i ._, � c�� �i
<br /> nppli,.mt's nddress S Phonc Number:_ '� — '� � I—•� ��o�-O r i j
<br /> ' ' � .: ;. _' 7`1 `� `� - ,—;_._I I
<br /> �� CROSS CONNHCTION CONTROL SUMMARY ASSESS�1EI�T�ACKCLON'RGQUIRED� �S NO (p/ /D
<br /> 7'y�e of Dcvicc: _ Sizc of Ucrice CCS Imtinls:i._�— Date:�!`}
<br /> i �
<br /> APPItOVI�� AlUI:I1.7'4:0R'AT6IiDISTRICI' /
<br /> 13���. //����� Uate �i��'`�'' Issucd Bp. .'
<br /> j _
<br />
|