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MUKILTEO WATGR DISTR[CT �
<br /> APPLICATION FOR WATER -�
<br /> i �Meter Size: ���� Service Address: � ���-"�'` � '" � � Aat.No.: I G I �T' � '
<br /> Number oFUnits: . �
<br /> ^ 'Meter will be used for(chec4;all that apply): �'� Domestic Irrigation Fire Service Firc Line
<br /> I hereb}•apply for water sen�ice and agre�to bc govemed,in accord�nce with the resolutions,rules and regulations of the MUI:ILTEO WATER
<br /> DISTRICT(�1WD)pertaining to water service,now•on c�reafter in cffcct. The undersigncd as o�vner or representntive of[he hercin-described
<br /> premises hercby agrces as follows:
<br /> (1) The consumer agrees to insmll,opernm and maintain at all times,�heir plum6ing sysmm in eompliunce with the curtrnt edition of tlie Unifortn Plum6ing
<br /> Codc u it penains to�hc prevcntion o`contamination,and pmtcction(mm thertnal cxpsnsion due m a closed system that could occur with Ili:prcsent or
<br /> Pow�e installation of backllow prcvcnmrs on thc consumcr's servicc and/or at plumbing fixwrcs.
<br /> (2) Th:consumu agrccs io instell all 6a:kflow prcvcntimi azscmblics rcqucstcd by th:MWD,nnd ro maintain�hosc backflow prcvention ass:mblics in good
<br /> working ordec The assemblies shall be of a t}7+c,siu and mal:c approved 6y the MND and ihe Washington Stam Departmrnt of Healih Authorip�. The
<br /> ntsemblies shall he instalied in accordance with¢II stantluds established by Ihe MWD.
<br /> (3) Thc w�atcr mcter will not bc installcd until a watcr usc survcy haz bccn submincd Ly thc applicant ond th:Districts Cross Conncction Convol Spccialist hu
<br /> dctcrmined if thc customcr will nccd�o install u ba.kfloa prcvcntcr on the customer's side of th=meter.
<br /> (4) That th:cost of any cxtrnsion of Ihc wamr scrvirx,rrncwal,rcplaccmcnt or rcpuir io ma:h and srnc thc propcny dcscribed shall be bomc by mysdCor
<br /> acsigns a�owncr(s)of thc prcmis:s.
<br /> (5) That all pipes,w•ater mcazuring devices md other connection equipment upsveam fmm the meter shall,atier�hcir instaCation,be and becnme Ihe pmp�rty o(
<br /> � Ihc MWD,subjcct to all its rcgulaGons pctla�ning to u'ater scrvicc.
<br /> (6) Thnt afmr installation,if mcter or mc�cr box and appunennnccs�uc buricd or damaged,tno owner,x�ill b:h�IJ raponsiblc and charged for same.
<br /> (7) Th�t thc tdW�,it;oRccrs and agcr,is,shali havc 6u ri�t uf ingress and cgmss to go u{ron th:premiscs and pmpcny dcscribed hcrcin for��c puryosc of
<br /> inspertion,connecling or disconnecting tlic service or(or such o�her purpuses as�he scrvice ma}�require. It is also understood durine Um tim:that any of
<br /> thc water mains may b:nut of scrvice by rc�aon of nny emergency or improvemena au�horiud 6y th:MWU,in any suret or other locatior,in which they
<br /> may have becn I¢id,ihc M WD w�ill not b:requireJ io fi�mish water during thc progrus of su:h impmvcmcnts to any ronsumer whos:xupply may thus bc
<br /> cut off,or b:li�lc(or any damagcs for ics failure m do so.
<br /> (S) That the MN'D shall have Oie ri�ht to change the mtes at any�ime by Hesolutian,b temporarily discontinue the sen�ice to consumors,and ro instali th=
<br /> me�er(s)to register the�rater consumcd. 7h:1.f WD sh211 nct bc hcld 1ia61c for d�unnge by water or n6icr cause resulting L-om defective plumbing or
<br /> xpplia�ces insiallcd by�he o«ncr or occupant on th-prcmiscs supplice witn wnte;,and ilic fact ihat agents of the MR'D moy havc inspected�h:plumbing
<br /> and appliancct shali not bc plcad as a buis for rccovcn•in ca�c o(darnagc as a(uresaid. ICth:supply of watcr shull faii or bc inmrruptcd 6y¢ycon oC
<br /> accidcn4���'pres,ure or o�hcr causc whatsocver,lhc M11'D shall not b:hcld liablc for damaen nor shall;uch(ailurc or interruption for any rcazonabl=�imc
<br /> bc held to constimte a brcach of conuact on th:pari et�he�1WD or in any way relic��c�he consumer,ahether tenan!or owner,Gom per(orming the
<br /> ohlieation of such tcnnnPs or o�sncr's contract. Watcr shall b:uscd by�applicant only on thc prcmisos dascribcd hcrein. A ncw application shall bc filcd
<br /> should watcr bc dcsircd for nihcr prcmiscs allhough lo�a�cd on land dcscribtd hcrcin.
<br /> (9) That lhc A7\{'D rtrnmmends inslallnlinn nf n pressure rc�ulatin�valvc. Appli:ant ecknowledges informnlion as to lhc rcrnmmendxliun and
<br /> -- . nssumes full resp��nsibilitc for inslallin�ur failin�lo in+mli a pressure regulnling ralve on Ihe wnter sysiem lo prolett it from hi�h
<br /> pressurc._I�'7'.
<br /> �-- (10) Phe A7\1'D uliliats chccA cub'es al�hc meter to prcecn[x'aler re�urnin;;to U�e UistricB mains. Thc�TND recommends insmlln�inn of a thcrmnl
<br /> expnnsinm m�k ta prevent euessive pressure builJ-up caused bc the water healer. Applicane acknox�ledges informntian as to the reeommendation
<br /> nnd aesumu full ruponsibilih'for inslalling or failin,q�n instull u Ihcrmal czpansiun Inn{:._I�T.
<br /> � A�-• r:'.''., . , r / • LOTNO.: BLOCK:
<br /> SGRVICG ADDRESS: � � ''` , -
<br /> - .- ,� ' •`" PLATNAML: � �``�� ' ^ �
<br /> CIl'Y/STATI7ZIP: ' � �
<br /> - �� ;; - .�,-:.
<br /> OWNER'SNAME: � �� " � � "� -� � � � LEGALDESCRIPTION: %� '� ' �� - '� -
<br /> �- !i✓ '1'i`%
<br /> Ol5'NEF'S ADURESS: - - - -
<br /> CITYISTATFJZIP:� - ' - - � "- �LDG FERMIT ISSUED BY:
<br /> Tlic premiscs arc la be usod aa n `'��� ` INFOFtM17ATI0N LE'ITER GNEN: --
<br /> StRVICP TYPE' CHARGF:S�
<br /> 1�� I Scrvicc installntion&conncction chargc S �'������'"�
<br /> Devcloper instalicd: � ) :
<br /> Distri.t Installcd: (2)Gcncral Pa:ilities conr.r.tion chargc 5
<br /> ,: �:7? G'.
<br /> District Insmllcd ruWrc: (3)O�hcr 5--�--
<br /> " ':�/' =�-�
<br /> Totul amount rcccivcd a�iUi npplicntion 5 - _
<br /> IT IS UNUEI;STOOD tliat this Application,nlihouph signcd,shall no;6=bindinc upon th-MUI:ILTEO N'A'IER DISTRICT until npproved by U¢DISTRICT.
<br /> - ;` .
<br /> I,the und:�siFneS,owner(or repmsenWtive)o(th:property Jescribed obove,do hemb��maAc a�plr:ation fo;installation of a - -inch diometer wx�cr supply
<br /> sen�ice connection,including appunenanecs,and all necessnry Iabor nt my expenus.
<br /> Datcd this � dar of�. � � _
<br /> ,: _
<br /> .4PPLICANTS'SIGNA'NRB:_� � � -" � -- r1 n f�
<br /> Applicant'sN.�vnc(Plc;�scprinl): - . . - '••-�•�•��
<br /> _ � � � i ��.�. _ . �.�� i_.� ..
<br /> ApplicanCs Addrcsa d:Phone Numbec_ - - - , . QEC 10 p'�
<br /> i
<br /> CROSS CONN[CTI01�COKTROL SUM�fARI'ASSESSMLNT DACI:FL0�5'RLQUIRED? _ YES _ '��_NO � 1/��I
<br /> 'I')pcoCD:��icr. SiuofUcvicr. CCSlnitinls: ':���--� Datr. �> : • i CC; `'V L��
<br /> r� �
<br /> APPRO\'CD:� AfUI:ICI'ti0��'ATERDISTRICT � J _�
<br /> py,: �f/�G'�-- _ Date /hy�/.Jj/�eYu IssurA By: � .
<br /> o�
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