|
MUY.;LTEO WATER DISTRICT
<br />APPLICATION FOR R'ATER
<br />— n ` • I, �
<br />Meter Sizc: ��`� Service Address: � 7� 7— ��~� ��r f U;' ,,," r„��"
<br />Numbcr of Unit�
<br />� Meter will be used for (chec4: all that apply): X Domestic Irrigation Fire Service
<br />��
<br />V"
<br />Acct. No.: ���_ �
<br />n�oa3a�1
<br />_ F�re Lmc
<br />I hereby apply for water service and agrce to be govemed, in accordance wilh the resolutions, rules and rcgulations of Ihe MUKILTEO W:1TER
<br />DISTRICT (MR'D) pertuining to �sater servicc, now or hereaRer in eftcet. Thc undersigned es owncr or repres:ntative oCthe hercin-described
<br />premiscs hereby agrees as follows:
<br />(I ) 'flic consumer ngrecs to install, operaic nnd meimnin a; nll times, thcir plum6ing system in compliencc wNi ihc curtrnt edition o(�he Unifortn Plum6ing
<br />Code ns it pcnains to thc prcvcntion oCwnwnination, a�d p:omction fmm thcrmnl czpansion duc to a closcd systcm Ihnt could occur with Ihc presrnt or
<br />Fuwrc in,tnllation of hacktloe� prevcnters on Ihe consumePs scrvice nnd/ar nt plumbing fi�ctures.
<br />(2) 7ho consumer uerecs to install WI backllmv prcvention assemblies reques�ed by tlie MWD, nnd to mainmin those backllow pmvention assemhlics in gooJ
<br />u�orking ordcc Tn, ;uscmhlics shall bc o! a typc, sis nnJ ma4:c eppmvcd bp th: 61 WD anJ th: R'achington Stau Dcpartmrnt otHealth AWhoriry. Thc
<br />asscmblics shall bc installcd in accarJancc wilh all standards cS�ablichcd by tlic M WD.
<br />(3) Thc u�atcr macr will not bc installcJ until a wa(cr usc survcy has bccn submittcd hy thc applicant and thc Districts Cross Conncctmr. Convol Spccialisi h;u
<br />dncrtnined i(if�c customer will necd lo install a buck0ow prevenler on �he as�om:r's sitle of th: meter.
<br />;A) Thae thc cost of:my cxtcnsion olthc wa�cr scrvicc, rcncwal, rcplaccmrnt or rcpair m reach and servc thc property dcscribcd shall Se home 6y mysdf or
<br />usiens at owncr(s) nithc pmtniscs.
<br />(i) That all pipes, water mcasuring devices and olha conneclion equipment upstrcam fmm We metu shall, af¢r Lhcir inslallation, be and become (he propeny of
<br />Ihc �714D, subjcct to all iLa rcgulations pertainins tu q�atcr scn•icc.
<br />(G� That aller installalion, i(melar or mner boz, nd nppunenances ve huricd er damaged, th= owner, will hc heid rcsponsible and chargod for same.
<br />(?) Tha[ thc MWD, ils oRcers and agcnts, shall have Wc rigfu of ingmss nnd egmss �o go upon Ihc premiscs and prop=rry' dcecribcd hcrcin fur thc purposc of
<br />inspection, connecting or disconnecting �he service or for such other purposes as the scrvice may myuire. It is also unJersmod during the time 4mt an}� of
<br />thc watcr mains may bc om o(servicc by rcason of any cmergency or impmvemcnis authoriud by thc M WD, in any suact or other Iocation in whfch they
<br />mac havc hecn laid, lhc A1 WD will not b: requircd tn (umish wala during thc pmgress aCsu:h impmvemcuts to any consumcr whose supply muy lhus bc
<br />cut cIT, or b: liahlc for onv damaecs fnr its (ailurc to do so.
<br />(F) 7�ha[ thc �1WD shail hm•e tlic right to chnngc thc ralcs at any timc b}• Rcsolution, to Icmporaril}� discontinue thc scn•ice to con:umcrs, and lo install tlic
<br />mcicr(;) �n rcgislcr Wc u'atcr cousumcd Thc M WU shall not be hcld liablc for damag: by u•atcr or othcr eausc ruulting Cmm dc(ccG�•e plumbin� or
<br />applimces instnlicd by Wc owncr n; occupant on Ih: prcmiscs wpplics e�ith watcr, and thc fact that ucena o( thc M WD may hav: inspccted thc plumbine
<br />anJ applimiccs shali not bc plcaJ as a bazis for rccovcry• in cssc of damagc as aforcsuid if Uic supply o(u�ucr sh;�l (ail or 6: intcrtupled by rcason of
<br />accidcnf, low pressurc or otlicr cause wimLcncvcr, Wc MWD shall not bc hclG 1iu61c (or damagcs nor shall such failurt or intcrtup�ion for:mv «asonabl: timc
<br />b: hcld tn constimic a 6rcach o(contract on tlre �vt of �hc A1�5'D or in any w�ay rclicvc thc consumcr, whcthcr tcnant or owncr, from pcdorming ho
<br />obhcation of such tenanCs or mmcr's caniracL 15'atcr shall bc uscd by applicant only ou ll�c p¢miscs dcscnb=d hcrcin. A ncH� appliwtion shall h: filed
<br />should ��ater he desired for olher premises although located on land described herein.
<br />(7) 7h�� tLe 11R'D rttnmmenJs installa�inn o(a pressure rc�ulating calcu Applicant acknmvledges informntion as lu Ihe recommcndalinn und
<br />ussumcs fuU,respnnsihiliq� fnr ins�alling nr (ailing �o inslall a pressurc rcgula�in{; ralve un thc �rater syslcm to pralcct it from high
<br />pressura '•.U` 1 IN7�.
<br />Qfl) Tht �1N'II ulilius chcck ralres a[ �he mcicr to prrvent ���alcr rclurnin;; lU �he UiSf�ICLS ma105. ThC �1R'D recummends installatinn of a lhcnnal
<br />cxpansinn �ank In prcrcnl uccssivr prusurc 6uiIJ-up causcJ by thr walcn c�atcr. Applicantt�^knuwlcdges infnnnatian as tu thc recummcndatian
<br />und usumes (ulI respnnsihilih� fnr inslnilinr nr failin� tn insinll u tl�crmal cxpansion tanl�'✓�" �� INT.
<br />SERVICEAUDRESS: L1 �C I' J ., -� /•�c:_ �-� � LOTNU.�. � � 13LOCk:
<br />CITY/STATFILIP: L' �� -+� i� t W, '✓.i H '� �-::- �
<br />OV.'NER'SNAMG: /"�r'T.1c,��,� l��lr m-. -'�.�c.
<br />OWNER'S Af1DRE55: I C I��f - C= ✓�r r� �' •> �-� ti.%t;�.f °Z�� -� ��
<br />i — --�
<br />CITY/STA7'EILIP: _ - ��.; ; �r H i �i; )f 1 . •.-(...� y _
<br />77ieprcmiscsarcmbcuscdasa �' ��"" ''''� ^� ��N
<br />Y--
<br />SGRVI FlYP:�
<br />Dcvelaper Insmllcd: �
<br />District Installed:
<br />DistricUnsmllcd Fulurc:
<br />PLAT NAA1L�
<br />LEGAL DESCRIPTIUI�: �• �C' • i� � � �
<br />�,._�'• I' � 1� f� i^; �• 1 .
<br />DLDG PGRMIT ISSUED DY: 't-r :" L ��
<br />MFOR6fAT10NLF;TTERGIVEN: y
<br />CI IARGL-5�
<br />(1) Scrvicc installntion S conncction charge
<br />('_j 6enoral Fa:ilitios conncction char@c
<br />(3) Othcr
<br />Total nmuunt rcttivcd with application
<br />S
<br />���.C:�
<br />_j —
<br />� ���_ . ��`.
<br />L.._.L�
<br />IT IS UNULRSTOOU thm tliis AppGcaiion, although signcd, shall noi he binding upon thc MUI:ILTEO WATER DISTRICT until approved hp ilr. DIS'(RICT.
<br />��,:
<br />1, thc undersigned, o��ncr (nr rcp!cscmativc) of thc propcny describcJ aborc, do hcrebr maAe application (or installation o(a ��� -inch diam:�cr w�a�er supply
<br />service conncctian, including appuncnyiccs. and all necessn�� labor at�ny ezpcnses. �y��D
<br />Datcd Ihis ; ... � "�, Jay of � -• _ . . _ � "�
<br />_ �: J
<br />APPLICANTS' SIGNATURH: L 1"��"�"�� �� I`1 .✓"-(� I n
<br />�,,a,. ���r ��c.� �-, �un o � zoo5
<br />Apphcant's Nunc (plc.uc prinl): � r � i,�L � � � i.; �^ ��' ... �. �� . .. n. ' �
<br />Applicant'sAddrcts&PhoncNumbcr �; i..i ,`i.: � f•.•. '_.�r__r r'1,-�.-i: _ � ,riIP:TCii � �•^r!��✓��
<br />t . � �.
<br />—=/ L...,I_.__ l;':.-=i: , ...
<br />; ;_��-� `i:��—l.;e��l . ..
<br />/
<br />CROSS CONNL•CTION CONTROL SUAfAtARY ASSESSMGNT 13.qC1:FL0\C REQUIRHD?�BS �� NO
<br />Typc ufDevicc: Sim of Dcvicc CCS Iniiials: i�✓ Date ���"/C�
<br />�— —T—
<br />APPHO\'Y.Ir � tU61LTF.0 N'ATGIt DIS'fRICT � �
<br />%��'�. � -
<br />I3�' _ i Da1e. �/�Oo 5 IssucJ F3y: �-%"•,
<br />�, ,
<br />
|