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ji MUKILTEO WATER DISTRICT
<br />APPLICATION FOR WATER
<br />Meter Size: Service Address:
<br />Numbcr of Uni
<br />'Meter will be used for (check all that apply): ✓ Domestic Irrigation
<br />Fire Service
<br />Acct. No.: —1nL _q3
<br />Fire Line
<br />I herehy apply for water service and agree to be governed, in accordance with the resolutions, rules and regulations of the MUKILTEO WATER
<br />DISTRICT (MWD) 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 consumer agrees to install, operate and maintain at ell times, their plumbing system to complisocc with the catmint edition oT the Uniform Plumbing
<br />Code as it pertains to the prevention of contamination, and prntecuon from thermal expansion due to a closed system that could occur with the present or
<br />future installation of backfiow preventers on the consumer's serviee and/or at plumbing fixtures.
<br />(2) The consumer agrees to install all hackfinw prevention assemblies requested by the MWD, and to maintain those backfiow prevention aremhus in good
<br />working order The assemblies shall he of s type, sirs and make approved by the MWD and the Washington State Department of Health Authoray. The
<br />assemblies shall he installed in accordance with all standards established by the MWD.
<br />(3) The water meter will not he 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 In install a bwkfinw prevents on the customer's side of the meter.
<br />(4) That Lie cost orm , extension of the water service renewal, replamment or repair to reach and serve the property described shall be home by myself or
<br />assigns as owner(s) of the premises
<br />(3) That all pipes, water measuring devices and other connection equipment upstream from the meter shall, after their installation. he and become the pmpenv of
<br />the MWD, subject to all its regulations renaming to water service
<br />(6) Thai ells installation, if meter or melet box and appurtenances are honed or damaged, the owner, will he held responsible and charged for same
<br />(7) That the MWD, its officers and agents, shall have the tight of ingress and egress to it, upon the premises and property described herein for the p,irposc of
<br />inspection, connecting or disconnecting the service or for such other purposes as the service may require It is also understood during the time that my of
<br />the water mains may be out of service by reason of my emergency or improvements authorized by the MWD, in anv street or other location in which the%
<br />mm have been laid, the MWD will not he required to famish water during the progress of such improvements to any consumer whose supply may thus be
<br />cut off, or be liable for any damages for its failure to do so
<br />(x) That the MWD shell have the tight to change the rates at any time by Resolution, to temporarily duconimuc the service to consumers, and to install the
<br />meterts) to register the water consumed. The MWD shall not he held liable for damage by water or nther cause resulting from defective plumbing or
<br />applimces installed by the owner or occupant on the premises supplies with water, and die fact that agents of the MWD may have inspected the plumbing
<br />and apphmccs shall not be plead u a Buis for recovery in case of damage as aforesaid If the supply of water shall fail or he interrupted by reason of
<br />accident, Inv, pressure sir other cause whatsoever, the MWD shall not be held liable for damages not shall such failure or interruption for any reasonable time
<br />be held to constitute a breach of contract on the pan of the MWD or in any way relieve the consumer, whether lenient or owner, from performing the
<br />obligation of such tenant's or owner's contract Water shall be used by applicant only on the premises described herein A new application shell he filed
<br />should water be desired for other premiss although located on land described herein
<br />('I) that the MWD recommends Insiallatimi of a pressure regulating valve. Applicant acknowledges information as In the recommendation and
<br />assumes falF jr, othillly for installing o r failing In install a prtssure regulating valve on the water system to protect Il from high
<br />C , presuve.l f,l IN7.
<br />(till Ihr hIN'Is utilims check valves at the meter In prevent water returning to the Districts mains. The htw'U recommends installation of a thermal
<br />expansion tank to prevent excessive presume build-up caused by the water heater. Applirasttp,�knnwlydges Information as Ica the recommendation
<br />end assumes full respansibility for installing or failing to install a thermal expansion tank (f_ 1141'.
<br />i
<br />SERVICEADDRESS:? J._J l_ LOT NO.: 'nJ _Itl.(3CK:_
<br />jF
<br />CITY/STATFILIP: _.___ PLAT NAME.
<br />OWNER'S NAME: 'I/ _ LEOn LDESCRjP1TON: I —r/`;
<br />OWNER'S ADDRESS:/!C. / `• :J
<br />CITY/S7ATL'/ZIP:
<br />J� �'.r� RLDG PERMIT ISSUED BY:
<br />_
<br />The premises are to be used as a
<br />SERVICE TYPE.
<br />Developer Installed _ V
<br />District Installed. __
<br />District Itmalled Ful»re. ___ __
<br />INFORMATION LETTER OWEN:
<br />HARGES
<br />(1)r) Service installation R connection charge
<br />(2) Ocructel Facilities connection chug,.
<br />(3) Other
<br />Total amount raeived with application
<br />5l,
<br />S
<br />e /J ")
<br />S r �"
<br />IT IS UNDERSTOOD that this Application, although signed, shall not he binding upon the MUKILTEO WATER DISTRICT until approved by the DISTRICT.
<br />1, the undemgned, owner (or representative) of the property described above, do hereby make application fat mi tallau" of a •inch diameter weer supply
<br />service conrx�(ion, including spiturtersapces, and all neceasay,) at my expenses.
<br />Dated this ' _ day of F
<br />\((
<br />APPLICANTS' SIGNATURE. ! �M� 14 '�r r A� 'till 6,0 f ^( PAIR"
<br />Applicant's Name (please print) to MrI L e\ f , tyke A
<br />Appticmt's Address A Phone Numbs
<br />G b(ax ujc. t u r r f) If rf'T F Lsd A t vl AUG 11 Os
<br />CROSS CONNECTION CONTROL SUMMARY ASSESSMENT RACKFI.ON' REQl1RtED? 2 N0 �� '
<br />Type of Device: Sin of Device CCS Inflisls Dab. , /
<br />APPROVE
<br />/��J MUKILTEO WATER DLSTRICT
<br />Er r/(X . Date _ Z/%ne9' Issued By:
<br />
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