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� MUKILTEO WATF.R DISTRICT
<br />APPLICATION FOR WATER
<br />Metcr Sir.e: � Service Address: % �� ' � � ��
<br />Numbcro(Unils: �
<br />Meter will be used for (check ell thet apply): �'_ Domestic __ Irrigation _ Firc Service
<br />AccK. No.: �1 I � J
<br />Fire Line
<br />I hertby epply for water service end egree tn he govemed, in eccordence with the resolulions, rules and rcgulelions of Ihe MUKII.TFO WA7'ER
<br />DISTRICT (M WD) petteining to wnter service, nnw or hercaller in eRect. 7'he undrrsigned es owner or representetive of lhe htrcin-descrilxd
<br />prenises herchy ngrecs es fnllows. �
<br />( I I 'Ilie ennxumer �prtrs In inslnll, npemle end mnimein el nll limee, their plumh�ng syslem m complience wilh Ihe curten� edilion oftht Uniform Plumbing
<br />C'a1c ns il petleins in �hc pmvrnlinn n(conuminelinn, end prntection Gom Ihartnal capeneion dua In e clnud ey: tem thet could occur wilh Ihe prexnt a
<br />Polure inx1e11eGnn nf Aeckllnw prevenlers nn ihe cnnsumer'e eervice enNnr el �.:umM1ing fixtures
<br />(21 lfie consumer egrtts in inslell ell beckflow provrntion avaemblies requated by the M WD, end to meintsin th�xe b ck0ow prcvention uxmblia in goad
<br />xnrking nrAer lhe dsemhlies ahell Ue nf � lyne, ei�e md meke epproved by Ihe M WU end Ihc Wn�hington Sute L4putmrnt of Heallh Aulhonry. 'Ihe
<br />essemM1lics shell hc installed in ecrmdence with ell etendude auhliihcd hy �hc MWD.
<br />Q) 'Ihe weler metci will nnl M inslelled unlil e weter use survey hm M1ecn suhmilted hy Ihe eppGcenl end Ihc Diflric8 Crme Conneetion CoNrol Speci�lis� hu
<br />J<Iermined if Ihe cuslomer will netJ In imtall e bnekOnw prcvenler on Ihe cuslnmer's fide ntihe meter.
<br />(41 Thei Ihc cnsl of eny eetemion n(Ihc wnl<r ecrnce rcnewnl, replecemem nr repnh lo reech end servt Ihe prnpeny deecriheJ �he116e M1ome Ay mysel(or
<br />nscign+ ns nwnar(s) �f Ihc prcmhcs
<br />� S� 'ILeI ell pipes, waler mrnvurinF dev¢rs enJ nlhe� connecliixi equipmem upsl¢nm Gum Ihe melar shell, slter Iheir mslallauon, Ue end bta+me the property of
<br />Ihe M WU, suh�<a In ell ac rcgulalmns penaining lo welcr scrvice
<br />(G) 1Te1 efter inslellnuon, il meier or meta M�a end ey�punenences erc FuncJ m dnmeged, lhc owner, will Le held rcepnnshle and chugeA fnr aeme
<br />(1) lhn� Ihe MWU, ils ulLcers end egenls, ahnll beve (he righl nf mµras end egrss lo ga upnn Ihe p2mises end pt�crty described hercin for Ihe purpou of
<br />inspeclion, cnnneclinp or Jisconnecling Ihe servict nr fnr such olher pur�ses a+ Ihe service mey rcquire. h is elso undeMood dunng the limr �hel �ny of
<br />Ih< weler meins mey be mn nlservice by rrnson of eny emergrnry nr improvrmrnls eulhnrissd h) Ihe M WD, in eny atrcel or o�her I�¢alion in which �hey
<br />mey hare Aeen Inid, Ihe MR'l) will nol Fc raqwred In Pomish �reler during �he pmgress n(mch improvemrne ln eny mmumn whose supply mey Ihus be
<br />cul oR, or be Geblc fm ony demegcs (ai Ils feilurc In dn so
<br />(A) lhei lhc MN'U shall hnvc U¢ nghl lo chongc Ihe reles ol nny Gmc hy Nesolulion, ln Iemprrerily discnn�inue Ihe srrvice In consumen, end lo insUll Ihe
<br />meler(s) In regis�er ihe weler consumed 71m MWU shall nm he held liebk f�x demege hy weler or o�her cause reeuhing fmm defeclive plumbing or
<br />epplienees inslelled by Ihe owner m necupant nn the prcmises su�6es wilh weter, end Ihc lecl lhe� egenls nf ihe M WU mey hwe iropeekd Ihe plumhing
<br />pnd appliences sholl nol Ac pleeJ es n bs�is fnr recnvery in cue of dnmege u dorcseid. If Ihe supply nf wekr shdi feil w be inlertupted by remon of
<br />eccidenl, Inw prtssum nr nlhcr cause Hhetsrcver, lhc MWU shell na� Ae hdd Gehlc for demeges nnr shell snch (eilum ar interruplion for eny rcuoneble �ime
<br />be held In cnnslilule e b¢ecb ol mnlrecl on Ihe petl nf Ihe MWU nr in eny wey rt6eve Ihe wnsume, whelher �enenl M owner, @um performing Ihe
<br />nlrliga�inn n(such Ienenl's nr oHner's coNrect Wn•.cr shnll Ire �rsad hy epplicem only on Ihe prcmises dacribed herein A new epplicaUon Shell be filed
<br />shauld wnlrr br deehed for mher prrmises ellLmgh lacaled nn lend dneribed hrrein
<br />�9) 7'hu Ihr 51N'll recommrnds Imull�llnn af � prneurr rrpul�tlnR v�lve. Appllc�nl �cknnwledRn Infnrm�tlon u lo Ihr rccommend�tlon �nd
<br />�uuma full rt�pandAlllry� far In+IdIInR nr fdllnR lo Ina1�0 � prrseurc reRu1�11nR vdvr on Ihe w�ter ty�lem In prolrcl II from hlQh
<br />prn�urt. IN'I'.
<br />QO) Thr M11N'D u111fza chrck vdrn �I Ihr mrlrr Io prevenl w�lrr rrinrninR In Ihe I/Ielricle mdns. The MWD rtcommend� Imldl�tlon af � Ihermd
<br />rip�naion I�nk lo pr�veN esrnilrr prnaure hulld-up r�u�ed by Ihe n�lrr hnter. Applinnt �rknowlydRn Informulon u lo Ihe rcaommend�lion
<br />■nd �esumee full rt�pundhlllt�� fnr Imulllnp or 6111ng lo Ineldl � Ihrrmd etp�rolnn I�nk. IN'f.
<br />til!RVICf:AUI)IillSti ' � ' � ' , . � � ' L(1TND 'I BLOOK.
<br />c911'/til'ATPI7.IP. � � PI.ATNAML � � ' � --
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<br />I)N'NI:R'SNAMIi� ��' � . �!� n.•�.�� � I.If1iALDliS('RIPTIONt '
<br />UN'NI;R'SADUNLSS. / ' : �� .� �: �; � . .
<br />1911YtiTATP/7.IP. ' � � .. . ' �-� %� 111.IH3 PIiRMIT ISSUf?D flY:
<br />7h< prcnuses erc io Me uscd ac e__ ���- __,__ ___ _ MFORMATION I_I�`ITI:R CI�VF.N:
<br />S[:Rl'LCLSYLf:_ S:11AN41:S. //gJ
<br />Devdoper Inslalled (� _ ( U timia ins�elleli�m � ennnecGnn charge S 7 JJ •��
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<br />Ilisi�iol Ine�ellcd. 121(icn<rel I'ucildrts cnnnecGon chmgc f '��� ., �
<br />Pistncl Imlalled Pulurt�. (3) Uthcr S
<br />--��� Tnlal emoum rtccrrcJ ailhepphceunn S_ -.�-'. ''
<br />I' IS UNDI'.HtiilX)D Ihe� this Applicauan, nitl�augh signcd shnll nnt hc hinAmg upon tlu MUI:II.7T0 WATf:R DISTRICT unlil epproved 6y lhc DISTRICT
<br />I. 19f IIOJ[fS1811tA, UNpfl I�< «�fCS[IIIBI Iif) i�� Illf �l0(ICII) doscnFcJ ehavc, Ja hercby mnkc eppliceuon fnr ms�elluion of e � -inch diem�er^; i� upply
<br />sen ice cnnnee�ion, including eppunenan�es, end all necessep� Inhor et my e�Mnsee �
<br />I)n1eA Ilns ___ _ __ __ da) ol' . . ,,.
<br />AI'I'I Il'ANfS' SIIiNAI'IIRP _ ._ _ ' ' �
<br />Appl¢enl'aNemclplrnscpriml ______`__�._______
<br />ApphcenYa Address & Phone NumFcr ______
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<br />_-T,.M!f�!,,;, � ,
<br />CHOSS l'ONNIiC1lON CONiROL SUMMARY ASSfiSSMENT BACKFLOW REQUIRC�? YF6 NO /
<br />7)�panllkcuc _ __ _ ___ ____ __. SizcofDevice CCSIniSuIJ}.� Dy�'� /..�.-,
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<br />APPRO�'f:D: Ai1�KI1.l�k:OR'Al'ERDItiI'RI(T � �
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<br />' ISlUGA B)'. , �
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