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MUKILTf:O N'ATF.R DISTRICT
<br />APPt.ICATION FOR N'ATf:R
<br />Mcicr tiv.c. _�� Service Address: I.:,�=� u I_ ���� .
<br />Numbcr of Units: �— , J � �
<br />Me�er will be used for (check ell that epply) _�` _ Domestic Irrigation __ Fire Service
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<br />Acct. No.: g_ 1��' O
<br />nsoaaiaa �
<br />Pire Linc
<br />I hereM� nppl�� for wmer scrvice nnA u�.rcc lu hc FnvernoJ, in occardoncc with �hc rcsnhllions, rules end regulutinns nf the MUKIITEO N'ATf:R
<br />I IItiTNIC"I f�1W1)I penaminf tu wauer +rn�ice, nnw or herenfier m effect. 'f6e undorsigned es oaner m rcpresentnuva af the herein-described
<br />premiseti herehc nFrceti xs fnllow's
<br />i I � The cansumer eEmn �u msiali, nperem nnd mnintmn at eil Umes, lheu plumhmp svstem m cnmphenu wtlh Ihe eurtem ediuon o(Ihe Unifarm Plumbmg
<br />Gdr ds 11 penam+ Iu 1hc prrvenunn nl contemmnunn, end pinmcuon fmm �hemial eapensmn duc In n clnsed sysmm Ihet enuld oeeur a�tlh Ihe prcsem nr
<br />linurt msiallauon of hacAllnw� prevrntcrs an Ih< cnnmmeYs scrvicc end�nr ni phimhmg fizWrts
<br />C i 'fha amsumer eprces In mslnll eIl FnekOnw pmvencnn nssrmhhes ¢quealed hr Ihe A1N'D, and In memtem lhotc hecAOaa prevenunn esaembhes m gm�d
<br />wurkm� arAcr "I�hc as�cmhlics shnll hc n! n �rpc, svc mid meke eppnroed h� Ihc MWU enJ Ihr W nahm�nn tilale [kpenmenl of Heellh Authnnry Thc
<br />nvscmhhcs shall bc rostallcA m nccordenca �ntl� xll stendarA� cnahlishcd h�� Ihc MR'D
<br />I� � 'Ihe wmrr meirr will nnt be mclnllrA umil n uairr ua surve� hm hern submnieA by Ihe xpplicant end Ihc Datncls Cms� Conncetion Cnnirol Speciahn hu
<br />AelermmeA d �he cuqomer e�il I neeJ �n mslall u backflnw prcrrnter nn Ihe custnme's side of the meler
<br />i J i lhal Ihc cnsl ol nm extcnxinn n! Ihr wnln suvice. rcneauL rrplx<emcm oi rcpmr lo reech md ttrve Ihc prnpcm describtd shell he Fome b7 mysell Or
<br />Rcspns ns nwi�cnu nl Ihc prcmi�n •
<br />,. 'Ihe1 �II pipa, aemr mensnnnf Acvia�. end otlier cunnecunn a�ryipmem ups�rcem frnm Ihe memr shnll, eller Iheir mstolletmn, he enJ Fecama Ihe prupen,l nf
<br />Ihc �1N'I �, snhlcct tn ell ie, icpulaw,n•, pcnmmng i�� wmcr scrvmv
<br />i�� � �(hn1 nOcr mxlnlleunn, d meicr or mner hux viJ xppunene�mes ere bur¢d nr JamnEed Ihe axner, will hc he1A rcsponsiblc end chnrFed for seme
<br />i' � 7hal lhc A1WU. iLc olTme¢ end npenls, shnll hnvc Ihc n�h� nf mFress nnA egress lu go upnn Ih: prcmises m�d prnpem descnbeJ herem (nr tlm purpnsa nf
<br />mspeclinn, cnnnecunp nr dittnnnaung Ihe scrnec or fnr such nther purpaxe� n� tlie sen�ice mey rcyinrc h is elsn understond dunng Ihe ume Ihnt eny u!
<br />�hr wntrr mmm� mn� he uul nf sen•¢c M� rensnn nf em eme�prncr nr imprnvemenls eWhonrcd hc Ihe MU'U, tn nnq strcet nr nther Incnunn m wh¢h Ihey
<br />nm�� havc hecn Imd, Ihe MN'U will nm bc rcqwrcA In G�mah wn�er dunnp Ihe prngrcs. o�euch Imprmements In ent concumer whose suppk me� thus he
<br />ntl uf1, or br Lnble Inr mir dmm�gee fur iLs feihnt In Au co
<br />i h�• 1 hal ihc MN'I� shnll hnvc Ihc nFht In chunFr Ihc rNcS ol nm umc hr Resulunnn. �n Icmpurenl� �LxcnNinue ihr servin �n cansumeu, end Iu instelt tl�r
<br />nicirqs r tu rc�usie� Ihc waler cnncumrd �fhc A1N'U shnll nat hc hdJ hohlc lar demope hp wmn nr otha ceuse msullmE Gum Je(ttuve plumhmE oi
<br />npphnnccs mslnlhJ M Ihc uxncr nr nccupnm on ihr pmmac+ snpplrc� wilh x�nlcr. end Ihc (fln Ihet agcnls o(tlm MN'U mm hnvc m�pcc�cA Ihc plumhmg
<br />'lI1tI II�I�fIlO�L[� SIIJI� 00( FC �II[01I A� 0 F0.\B !n� recavon m catt nl demoge rt� efumseiJ If lhc wppl� a! welcr Shell fed nr Ac mlemipmA M rcnsan o!
<br />ac<idenL Inu pres�wc nr nlhm cnucc whetsuever, Ihe MN'U shell nm hc hrlA hehle fnr Jnnmgn nor sha�l auch Inilurr or wienupiinn lirt nm rcnsonable ume
<br />hc held In cunanme n hrench o( cnmr+n nn 1h: pnn ot Ihe Mll'I � ur m nm ax� rehevr Iho cnnwmer. xhether Irnunl or awner. Gnm pi�rfnrmmg the
<br />nhhpumn QfsuGi mmm��s m nwncr�� comran Unmr shall br uscd h� arphcant nnh nn Ihc prcmica Jc.cnhcA hcrnn A ncH npphonnun simll M1c fticd
<br />�houlA wnler hr AcsuvA Int nlhcr pmmivc� nllhnuFh IucalcJ nu Innd Ac�cribcd he�cm
<br />Ph �I h�t ihe �ll4-U rrcnmmrnd. im�dlatinn nf a prc�anr rtgulxun4 vdre. Apphrum eoknnHtrdCri Infurmniun n u� Ihr rtdummrnJ�lion xnd
<br />a�sumr�. lull rqpuwihllN� fnr inslullmF ��r failin4lu imlall e prrecurr rtF��lnlin4 vuhe nn Ihr w�lrr s;elem lu prnlrcl il Irnm hi4L
<br />prra�urr. .� � /. I\'1. -
<br />(1111 ILcMN'U uiilM�c dirrA v�h'ec �i Ihr mrirr la prnrm eelrr relnrning lu Ihr Iliqrici. maim. Tbr MN 11 rrrnmmrnA. inalidlabun ol x Ihrnnal
<br />rxpnntiun Imd. In prtrrnl trr<etirr prrr�urr hnilJ-up coinrJ h) ��ic wnrr hru�rr. Appllnm �eknnwlydFe. infornniinn �. io Ihr recnmmrndnlinn
<br />•nA axunm� full rty�omiLilln far inslalGn� nr laihng In in�Iw1I p Ihrrm�l r[p�nrinn IanA. __� � IN'1'.
<br />tiil:\9C'I: AUDI:fSti � ,_ _. � ` , -- . j� I . _ _ I ( �1 KI i ___ HI (It'!�.
<br />�'!Illt7ATGZlI __._ ___._ ., � / I'Ll,I14MI�. __��=_i 1 `/ '� , �� .
<br />iMNI:R'SNAA11 t`- .7_ ��, �J � i��� � - Ih:(iAIUI�SCHII'710N� �- �`�!�Y' �'� .
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<br />� n1'h'I:R'S ADIIRPSS � l " ; �", . �" � ��_
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<br />I h�: prcmiscs irc tn bc useJ n� e `-' � __ MF(1HM ATIUti I,1 "I'I'PJt (il YGN. __
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<br />�I�Ic�'I�L I�1'PI' 4llAR(il-ti � `rJ � �� ..,? .�.
<br />I �rvelu rr Inr'lalled � , �i �•'
<br />p �` (11 tirn�sc ros�nllnWm k cannccuon chergc S'�'�=�'�T'��i _
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<br />Ih�incllnslallcd ____ __ _ 21Gencrnl4u:i61mscnnnaunnehe�pc S � =�-" ,� -
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<br />I: IS UNUIiKSI( N1I11hat Uu� Apphceuan. elthauFh siEncd. sliall nut h: hinJinp upon Ihe MUGII: ffiU N�ATI�R DISTRICT until upprnved h� Ihc f�ISI RP�. f
<br />: mc unJersigined. ownrr Inr rrprrunlauvcl nt Ihc propcm dr.:nhcd nho�r. J�� herch� makc eppheauon lur msmllnt�on of n__!.� ���nch �6amcie• un�cr su�ld�
<br />.i�n ia cnnnectlon. mduJmg uppunenences. enJ all necescu� Ixbm a�-m� o�prntts
<br />I �mrA Ihn . dm a( . ' : - . . � ,
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<br />'J'191CAN'fR'tilciNATURC . w• � ��r.'U-/��
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<br />��PPImnnY+AAJress3PhnncNumMrr ._ �__r_-___�'--�—_�_�_-
<br />„ ; ... : _-_ , _ - PAID
<br />(ItNCSl71NNPl"Id��(ti\IR!�I tiVM�1AR1 ASSI[SSMIiAiAACF:fL(11CRPpUINP.D" 1'ES 7� NO,���/� ��F{i� '�°rn�
<br />'I �p: ui hcrrca . _ _ _ 5¢r of Uev¢e __ ___ __ CCS InNels �� G- Uale J:T
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<br />H� N. ^ -'1� I�a�c � � i- L✓�___' _ IssucdH�
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