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MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />Meter Size: 'h I Service Address:
<br />Number of Units:
<br />wfeter will be used for (check all that apply):
<br />✓ Domestic Irrigation Fire Service
<br />Acct. No.:-1n-;� Ll5
<br />Fire Line
<br />1 hereby apply for water service and agree to be governed, in accordance with the resolutions, rules and regulations of the MUKTLTEO WATER
<br />DISTRICT 0 WD) pertaining to water service, now or hereafter in effect. The undersigned as owner or representative of the herein -described
<br />premises hereby agrees as follows:
<br />(1) The ennwmet agrees to install, operate and maintain at all times, their plumbing system in compliance with the current edition of the Uniform Plumbing
<br />Code as it pertains to the prevention of contamination, and protection from thermal expansion due to a clotted system that could necur with the present or
<br />future installation of backanw preventers on the consumer's service and/or at plumbing fixtures
<br />(2) The consumer agrees to install all backaow prevention assemblies requested by the MWD, and to maintain those backaow, prevention assemblies in good
<br />working order. The assemblies shall be of a type, size and make ylprnved by the MWD and the Washington State Department of Health Authority . The
<br />assemblies shall he installed in accordance with all standards established by the MWD.
<br />(3) The weer meter will not be installed until a water use survey has been submitted by the applicant and the Districts Cross Connection Control Specialist has
<br />determined if the customer will need to install a hackl1mv preventer on the customer's side of the meter.
<br />(4) That the cost of any extension of die water service, renewal, replacement or repair to reach and serve the property described shall be bum by myself of
<br />assigns as owner(s) of the premises
<br />(') Thal all pipes, water measuring devtms and other cnnnection equipment upstream from the meter shad, after their installation, he and becnme the property of
<br />die MWD, subject to all its regulations pertaining to water service
<br />(6) That after installaiinn, if meter or meter box and appurtenances are buried or damaged, the owner, will be held responsible and charged for same
<br />(7) That the MWD, its officers and agents, shall have the right of ingress and egress in get upon the premises and property described herein for the purpose of
<br />inspection, connecting at disconnecting the service or for such other purposes as the service may require It is also understood during the time that any of
<br />the water mains may be out of service by reason of any emergency or improvements authorized by the MWD, in any street or other location in which they
<br />may have been laid, the MWD will not be required to furnish water during the progress of such tmpovements to any consumer whose supply may thus be
<br />colt off, or be Gable for any damages for its failure in do so
<br />(a) Thal the MWD shall have the right to change the rates at any time by Resolution, to temporarily discontinue the service In consumers, and 1n install the
<br />meler(s) to register the water consumed The MWD shall not he held Gable for damage by water or other muse roulung from defective plumbing or
<br />appliances installed by the owner or occupant on the premises supplies with water, and the fact that agents of the MWD may have inspected the plumbing
<br />and appliances shall not he plead as abuts for recovery in case of damage as aforesaid If the supply of water shall fail or be interrupted by rcuon of
<br />accident, low pressure or other cause whatuoever, the MWD shall not be held liable for damages nor shall such failure or interruption for any reasonable time
<br />he held to constitute a breach of connote, in the part of the MWD to in any wa) relieve the consumer, whether tenant or owner, bum performing the
<br />obligation of such Iceland or owner's contract Water shall be used by applicant only on the premises described herein A new application shall he filed
<br />should water he desired for other pram sc, although. located on land described herein
<br />(n) That the MWD recommends installation of a pressure regulating valve .Applicant acknowledges Information as to the recommendation and
<br />asvumes fYlhtyinnsiblli1% for Imldling nr failing to Install a pressure regulating valve on the water system to protect It from high
<br />pressure. L M INf.
<br />(In) the itwl) milires check valves at the meter to present water returning to Ile Districts mains. The MWD recommend, installation of a thermal
<br />c,pamion tank In prevent exeeisive presinre build-up cati,rd h) fl r wafer heater. Applies p minowledges Information a, to the recummendation
<br />anti Assumes full respnnsibilu) for in,talling or Idling In install a thermal expansion tank. ll TNT.
<br />SERVICE ADDRESS'�y -
<br />-- LOT NO.: BLOCK
<br />F r" L,
<br />CITYISTATE2IP: (+' _ PLAT NAME:
<br />OWNER'S NAME: LEOAI. DESCRIPTION, y
<br />G✓ -
<br />OWNER'S ADDRESS: �%/ • •/.: l/� yC.. r
<br />CITY/STATFJZIP: L-i, �� , ~ BIDG PERMIT ISSUED BY: _.
<br />The premises are in be used as a
<br />SERVICE:TYPE.
<br />Developer Installed.
<br />District Installed
<br />District Installed Future
<br />INFORMATION LETTER GIVEN:
<br />CHARGES
<br />(1) Service installation & connection charge
<br />(2) General Facilities connection charge
<br />(3)Other
<br />I and amount received with application
<br />S
<br />S
<br />IT IS UNDER°TOOD that this Application, although signed. shall not be binding upon the MUKILTEO WATER DISTRICT until approved by the DISTRICT.
<br />1, the undersigned. owner (or representative) of the propem described above, do hereby make application fin installation of e
<br />including appurtenances, and all naloo ecesiar)�st my expenses
<br />soma conneaioi�
<br />Dined ibis day of (
<br />APPLICANTS' SIGNATURE- � a//' A ^J"�`� 1U( Ot.Jn ► /
<br />Applicant's Name (picture print) D N9 e ( n, f I e) A OPA
<br />Applicant's Address & Phone Number: C (r In-,r (i.]P A' ate .4 r : t. I i I " v • 1
<br />CROSS CONNECTION CONTROL SUMMARY ASSESSMENT BACKFLOW REQUIRED?
<br />Type of Device: __ Sizer lhvice. CCS Initials Date F�
<br />APPROVED' IIKILTF.O HATER DISTRICT
<br />By Date: 0 7 %O99
<br />-inch diameter water supply
<br />PAID
<br />AUG : 7 99
<br />MWWD
<br />Issued By — -
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