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I'QiUI�ILTEO K'ATF.R DISTRICT
<br />APPLICATION FOR N'ATf.R
<br />Meter tirzc ��`� � �� - . � � �. _ - �
<br />ticndcc Address. �
<br />Number of Unirt: 1 ----
<br />Meter will be used for (checl; ell Ihet applyy: V _ Domestic _ Irtigetion
<br />_ Attc Nc.: ��� �
<br />(i Jo c`�, 31 �,
<br />Fire Service Fire Line
<br />I hereby epply (or weter servicc end egrce �n be govemed, in eccnrdence with the resolutions. rules end rcguleiinns of the MLIF:ILTEO K'ATCR
<br />DItiTRICT IM WDI pertnining �n wn�er aervice, now or hereefler in eRect. Thc undersigned dc owner or representndve of tha hercin-descrilxd
<br />premiscs herehy eFrees a follnwa
<br />! I I Th^ mnsumer apnes !n ineiall, npenm end meimein ei eil umes, lhar plumAmg s��stem m wmphence with Ihe wrtent eAdmn of Ihe Un�(nrrn Plumhmg
<br />CM< ns u penams In 1he prevenuon nf cnmammdmn, enA prnlecUiro Irnm Oirrmui ezpeaemn duc In e closed system lhsi rnuld accur wflh Ihe presem or
<br />PoNrr insullenon of hecktlnw prcvcnlcn nu 1hc cnnsumer'x ecmu endlnr et plumhing fixWrcs
<br />C I The mnsumer eaees tn mstell dl backllnw p� evrnnnn nssemhhes rcquested hc Ihe MWfI, end tn memtmn �hme beckOnw prevenuon assemhlms m pond
<br />wnkmF nrder The acxemhhes shell be nf e IpK, six end meYe tq�prnved hc Ihe IdW U end �he We�hm�fon Swe fkpartmem nf Iicelth Amhonrv Thc
<br />mscmhhes shnll Frr Ins�allcA in eccnrdenea wnh ell sianderds etlahlisheA Ar Ihe MWD �
<br />( ji Thc w�eler metrr xill nnt ba ma�nlleA unlil e wamr use surve� hn+ Attn suhmnied by Ihe apphcuit md Ihe DrstrieLs Gnss Connecnnn Convnl Speuehs� hu
<br />delermmed i(Iha custmmer wJl nceA In matnll a beckOne pmvemrr nn lhe cuslnmer's side af Ihe meler
<br />IA I lh�t Ihe casi nf em exienvnn nf ihr wn�rr srrvm<, renrwnl, mplecemem ar repmr In rcach md serve thr propetty descrihed sheil bc home by mysel(m
<br />msigns a� nwneqsl nf thc prtrusn
<br />(?I lhn all p�pes, wem� mcAsunnp dev¢es �nd alhu cnnnecunn eqwpment upslream Gnm Ihe metu shell, efler Ihar mslelletion. M1c enJ Aecnmr Ihe prnpeny n(
<br />Ihc M W U, suhl«� �n ell �Lt rcguleunns peeninme U, wmrr serv¢c
<br />(��1 'I h�t efler msulleuon. i( meler nr mcler hoi md eppunenences err AuneJ rn dnmopad Iha nwner, wlll be held mspnnsihle enA cher�ed lar snmc
<br />(71 Th�t Ihe MWU, �tr. olBcerx enA agents, shnll heve 11¢ nght nf ingrst enA egmsv In gu up�m Ihr prtmaes enA pr�eny descrihed hercm fnr Ihc pur��se of
<br />mspecunn, ennneclmp nr discnnnecung �he urv¢c nr for such mher purpnms tit Ihe serv¢c me} reqwre h �s akii understmd dunng �hr ume thet mv of
<br />Ihe weler mnms m�� be nu� of servrcc hc reamn rf env emerRenn nr �mp�m�emems euthonv<d by Ihe M WU, in env slreel nr nlher InceUnn m which they
<br />mm� hnve heen Iai4 ihe MN'f � wili nnt hc rcqutrnd In (umisli weicr dunn f Ilm prnFrrc� n! sucli impmvem:nls In em cansumer whosr suppl�� me}� Ihus he
<br />cm nR, or M hehk (or eny demepcs !nr ue fedurc In dn sn
<br />IP 1 'Ihet �hr MWI ) shell hnve Ihe nphi to chenpe Ihr re�es m nne umr hr Resohmm�, m mmponrilc disconunue ihe xrvme In cnnn�mert, end In mslnll Ihc
<br />nic�cqs i tu rcgislrr Ibc weltt contumed lhe MR'U xhell nnl h: held haMc for domegc hc wemr m olher eeuee tesulUng fmm defecuvr plumbmg or
<br />�I iul;rsaMi�llcJ hy Ihc nwner nr nccupem nn Iht prcmiscs xupplm Wnh wn�ei, enA Ihc fect thet eFenL, allhc A1WU mey heve inspttted Ihc plumbing
<br />nrtd eppLencu shdl nm he pleeA u e Amis Inr ¢cnven� m csse af d�upr�. ehuetniJ If 1he su�ly o( wemr shell leil ur he IMemipbd.h)_rcssur nf
<br />ncnarnt, lax pressurt m olher enuso wFeis�cver. ihc MWD shell nnt hc helJ Imhk (nr demnpe� nrn shnll such failure or imertuptian fnr enr muonnblc umc
<br />h: hdd u_. cypeuUket hreech n! cnnlnct on the pan nf Ihe MR'D or m enc e�nc rclmvc Ihc cnnsume�, whether tenent ar nwner, fmm per(urmmg �hc
<br />nh6Fetmn ol such lenenl �s nr naner s cumrau N'aler shall Fc used hy nppLeun onlc nn th: premnes described herdn A nca epphuGnn thsll be filed
<br />xhnuld weler hr devred fm olher prtmisn nithnuFh Lmeled rn� IenA descnbed hercm
<br />(�I 'Ihn Me#fNT �ecnmmrndc lmidluinn nf � prn�urr rrRul�IfnC v�ive. Appliant �rMnowledF« ���nrm�tlnn �s la Ihr recnmmend�Unn �nA
<br />ummee full rnpnnxibllfn� fnr inndlin4 nr fdllnF In Ineull � prnvire rt�ul�tinF rdrr nn Ihe wuer eplem ta prnlrct Itlrnm hi�h
<br />prn�urt' � i 1�'I�.
<br />(101 Thr MN'P ulil6n oherk rdva �t Ihr mr�rr In prrvent �rner relnrninF In Ihr IlletricB m�ins. The MN'I7 rt<nmmends Im�dl�lion af � Ihrrmd
<br />ripamian unk In prrvem ricra�nr pranrtr build�up nuerJ b� Ihr w�Irr hraler. Applinpl u4�pow�led�rx inlorm�lion n In Ihe recnmmend�lion
<br />■nd ummn 6d� rnpanniblliq lor msullin4 nr fdlinF In Ina�dl � Ihrrmd rtp�nefnn I�nL�. �/ 7M�.
<br />tifRVICG Af1f7NFti5 �� '� - � .. ,', , i� � r +. /
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<br /><'fI'1'/STAIIJ/.IP .� : ' ' PLATNAMF i- ' .',; . , .. , ..
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<br />tlN'NP.R'S NAMIS _ . . ' . . � j �• ,; __. _ I.PGA1 PFtiCRII'"fION r _-.��'(� . _. _ ___ -- .. _ .
<br />UN'NFR'S ADDRfSS _ '%�� -' ��� � i � �7�L, J '
<br />�'��f1'757'ATF'/.IP '� -.
<br />71ir prcmises ve �n he usrd a� e_ ��"
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<br />I1LD(i I'I(RMI7 ISSUGD !lY
<br />IVPOItM�T10N LP.1'!L''R GIVF.N. ��
<br />tif�;ItVICG TY!'E . ��k�;L..ti
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<br />1levelopet Iroulled �'__ (I1 Service installeunn B cnnnecu<M chergc S w=�-� �
<br />Uisu¢tlmidled ____ (?)CrcnenlPeci6Ucsconnecunnchergr S ��-�•�-'-3`��� _
<br />Ihsv¢IlnstellcJPumre ___ 131(Mhe S .
<br />TMnI emnunt received wnh epphcaUim S�` �'T 'J 7
<br />I i Iti UNDfR$TO;Ip Ihet Ihis Apphaunn. ellhauFheipned, shell noi hc bmdmp upan Ihe MUF:ILTIiO WA71:H DISTRICT umil �pprmeR'lif Mt�ISTRIc";-
<br />1. ihe undenigned oxner I�r rrpreseninrvr� ol'thr propem docubed Mme, dn hercbr mekc epplmauon (nr immlln�on o1 a ��/ t Ii�ICh dut�tMRRY suppl`
<br />�en�rce cnmrcepon, meludmF �ppunaunces. m�d dl neca�e� leho;y m�� expe�ns �
<br />! �.neA Ih�z � dm� of � -� ) '.
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<br />� -� %.� �a�-----�— MI�It�LTE� 1'';F:',=F P'.�Ti.'.I
<br />�U'I'!J�ANTS'SIGNATURF __� _'!
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<br />�pphcanCs Nunr �plcuc prinn _ _ __ � �' ' ,
<br />Apphcent's Addms & Phime Numher " _/_� _ . . ;� -. . � � ' . , � � . ' ` ' , • ,
<br />�'RUSSCONNP('TIONCUNTR(�; Si��1�fA1`1'ASSFSSM[NTPACI:PLON�RFQUIRED^ i-,YES v NO F .
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