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MUKILTEO WATER DISTRICT �
<br /> APPLICATION FOR WATER �
<br /> Meter Size: �/� Service Address: � �"'���"' �� �' �" � � Acct.No.: I O I Fi � �
<br /> _ Number of Units: � �
<br /> Meter will be used for(check all that apply): Domestic Irrigation Pire Service Fire Line
<br /> f hcreby apply for watc:scrvicc and agrce to bc @ovcmcd,in acwrdanee wi�h thc resolutions,rules and regulations of ihe MUKILTEO WATER
<br /> DISTRICT(Df WD)pertainiug to water scrvice,noa or hereaticr in eftect. Thc undersigned az owner or repiesenta!ive of thc herein-described
<br /> premises hercb}�agrees as follows:
<br /> (I) The consumcr agrca to instnll,operele and maintain at nll times,thcir plum6i��g systom in compliancc e�ith the curtcnt cdition of th:Unifurtn Plumbing
<br /> Cod:as it penains m tltc prcvention o(contamination,and protmtion fwm thcrmal expansion duc to a clused systcm�hat could occur with ih�prescnt or
<br /> fuwrc installntion of LackOow prevcntcrs on�hc consumer's scrvicc and/or at plumbing Lxmrcs.
<br /> (2) The eonsumer agrea to ins�ali all ba:k0ou�prevention usembiiu«quated by�he MN'D,end to meintain those 6acktlow pravention ossemoiies in good
<br /> working ordc�. Thc uscmhlia shnll bc o(a qTc,siu and mel:c approvcd by ih=hf WD and�hc Washino on S�atc Dcpanment of Health Authoriry. Tho
<br /> asscmbli:s shall 6e insmllcd in accordancc with ell smndards uts6lishcd by thc MWD.
<br /> (3) Thc water mcicr will nM bc insmllcd until n u'atcr us=survey has becn su6mitted by�hc applicent and ihc Dis(ric15 Cmss Connection Convol Spccialist haz
<br /> dc�crmir.cd iftl�c customer will necd to insmll a back0ow prevcmer on the cusmme.•'s sidc of ihe mctcr.
<br /> (4) ThT Ihc rnst nf nny ez�ension of the waler scrvice,rcnewal,replacemrnt a repair lo rca:h and scrve Ihe propetty described shall be bome by mysdf or
<br /> assigns ac oN�ner(s)of thc prcmises.
<br /> (5) Thnt all pipec,water mcazuring Jevices and othcr wnnection equipn•.en;upsveam from Iho mettr shall,atmr ihcir instailation,be and becnme ih:property of
<br /> thc MN'D,subjcct to all iLs regulations pcnaining to watcr scrvicc.
<br /> (() Thnt aCmr installntion,if ineter or meter 6oa end nppuncnanca are burid or damagcd,the oencr,will bc hcld responsi6le end chm@cd for sama.
<br /> (�� That tho MWD,its o(ficers and agcn¢,shall ha��c�hc nght oCingress and c@rus In go upon Ih:premises ond property dcsaibed herein(or thc purpose oC
<br /> inspection,connceting or disconnecung the scrvice or fo:such other pumoses ac 1he sen�ice may require. I[is also understood dmin;the time that any of
<br /> thc walcr mnins mu}�bc out oCscrvicc by rcuon of am��mcrgcncy or impmvcmcnLs acthorimd by thc M11WD,in any succt or other location in u�hi:h thcy
<br /> may hm�e becn laid,Ihe M11'D will not bc rcquired to fumish�cater during tire progress of such imprnvements to xny consumer whose supply moy ihus 6e
<br /> cut oR,or b:Iia61c for any damagcs fnr its failurc m do so.
<br /> (S) That We MWD shall hav:We right tn change ttie rntes at any tim:6y Resolution,to tempo`ariiy discontinuc the servire to consumers,und m install ihe
<br /> mctc�(s)tu registcr thc r,atc�consumcd. Th:MWD shall not bc hald Iiablc(or damagc by watcr or olhcr causc rcsulting from defcctive plumbing or
<br /> applianas insmlled by lhe o�mer oroccupant on the premises suppliu wi�h water,and ihe fact ihat ag:na nf the MWD may have inspeneJ th:plumbing
<br /> nnd applianccs shali not bc plcad u a 6asis for recovcp�in casc of damagc ns aforcsaid. If tim supplr of u•atcr shall(ail or be intcrtuptcd by rceson of
<br /> accidcnt,loe�pmssure or oWcr causc whalsocvcr,thc MND shnll not bc hcld Gublc fur damagcs nor shall such failu¢or intcrruplion for any rcatonabL^tim:
<br /> bc held to constiwic n brca:h af contract on the pan otthe MWD nr in am•aay rclieve tlic cor.sumer,�chetha tenant or oNnor,fmm pedomiing fhe
<br /> obligauon of such tenanCs or oH�ncr's contract. 0.'a�cr shall 6c used b}�applicant onl}�on�h:prcmises dcscnbcd hcrcin. A new application shall 6c Cilcd
<br /> should w�atcr b:dcsireJ for othcr premiscs¢IthouFli lacatcd on land dcscribcd hcrcin.
<br /> (9) "Phee Ihe\I\1'I)recommenJs inslallalion otn pressurc regulating celec. Applicxnt ecknnwledges informelion as lo�hc recommenJetion enJ
<br /> - ussumes fulbrxspnnsibility for inslalling nr(ailing tn insmll n pressurc rcgula�ing�'alvc un�he anter system tn prolec[i[from hieh
<br /> , pressurc. '� I�T.
<br /> . (10) T7¢�iND ulilizes checl:vnlves at U�c mcter Io prcccnl a�a�cr relurnin��o lhe Dislrius mains. Thc hiN'D recommcnds inslailntion of a thermal
<br /> expnnsion lank to prev�nl excessire pressure 6uild-up causeJ 6y Ihe ea�cn c�ater. Applicent,acknowledpes information as�n thc recommendalion
<br /> and assumes full respnnsi6i'q'for instulling ur failing to insmll u lhcrmal cxpansion t�nl:.__I�T.
<br /> i.
<br /> /-",Ci� �_ =�y�; ..�; , . ,• � LOTNO.: �CiLOCK:
<br /> SERVICHADDItESS � . " .
<br /> . ..� %���y��[� PLATN.AMG� i..'.. .,n.,-__
<br /> CITI'/STATfJZIP � -
<br /> r�VNGR'S NAME. - ������� � ���n�� �'� LEGAL DESCRIPTION: � � � `� ��
<br /> ,f: t',�'/
<br /> �,�ER'SADDRESS: —
<br /> CITI'/STATPIZIP: �LDG PEftM!T ISSUED BY:
<br /> Th:prc�ises arc ro be usod ac a '��f=�' INFOP.b7AT1ON L87TER GIVLN:
<br /> SFR\'ICE T1PE. CIiARGER� �_/ �_�
<br /> Dcveloperinstalled: �/ (I)Scrviccinstalln�iongeonnectioncharge S�_
<br /> Disvict Installcd: ('_)Gcneral Fu:ilitiu connection chargc S " � -
<br /> District InsuJlcd Fuwrc: (3)Otlrer 5 �
<br /> Totai amount rcccrved w�ith application S �" �� ����
<br /> IT IS UNDL•RSTOOD that this Appiication,although signed,sh¢II not b-binding upon th:MUI:ILTEO N'ATER DISTRICT umil approred by�he DISTRICl.
<br /> :�r, .
<br /> t,�h:undersigncd,o�ener lur repres:mative)of Ihc property descri6ed o6ov4 do hcrcb�•make npplicntion tar inslallation of o -inch diamcar water supply
<br /> I scrvicc cmmcctiun,including appuncnanccs.:md all ncccssnr}�Inbor atmy czpanscs. ^„ A (D
<br /> Daled this day of - LJ�,
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<br />( APPUCANTS'SIGNATURG:- � - DeC 1 O OB
<br /> AppGcant's Nnm:(Pleacc printl: '- � ... � - - "'- R/��/�/ /��
<br /> i,pplicanCs Addmss 6:Phone Num6 e ''"� - �' - - �� - � -��'� l '" � iy` y y� y Q
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<br /> CROSS CONNECfION C01�TROL SUMMAAI'ASSHSSMEI�T[3ACI:FLOK'RLQUIRLD? �YES �� NO r i 1Jz`,�
<br /> T}7�:ofDcvir: Sizc ofD:vice: CCS Initials: � "� Datr.
<br /> Af'PRO\f' 15;'j ANI:ILTGO�1'A'PICR DISTILICT /
<br /> �/ , . /L �j.��OO .� lssucdBy�. -. . .
<br /> D`': (/� � Date: / �
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