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UTILITY SERVICE CONNECTION APPLICATION
Community and Economic Development
City of Arlington• 18204 591h Avenue NE•Arlington,WA 98223 • Phone (360) 403-3551
Submittal Requirements:
1. Complete Application
2. 8-1/2" x 11" Site Plan/Sketch of the Proposal
3. Payment and Permit issuance is required prior to water meter installation
Type of Request: 0 Water Only ❑ Sewer Only ❑ Water and Sewer
Occupancy: ❑ Single Family ❑ Duplex ❑ Multi-Family 0 Commercial ❑ Industrial ❑ Institutional
Legal Property Address: 19620 67th AVE NE
Lot#: Parcel ID Nos : 31051500101500 Subdivision:
Owner Name: SNOHOMISH CO PW-Roads Div.1 Office No.: 425-388-6655
Email Address: Doug McCormick Cell No.: 425-508-2648
Mailing Address: 3000 Rockefeller Ave M/S 61 city: Everett State: WA Zip: 98201
Owners Agent: Eric Nordstrom Office No.: 425-262-2806
Email Address: eric.nordstrom@snoco.org Cell No.: 425-327-4179
Mailing Address: 3000 Rockefeller Ave M/S 6 city: Everett State: WA Zip: 98201
GENERAL INFORMATION
Give a brief description of your proposal and/or request:
Application for water meter installation for main permit number BLD-6487. For utility billing purposes please use Tasha Colson as
contact(425-388-3193;SFM-Payables@snoco.org;mail=Snoh.Co.Roads Div.1,ATTN FACILITIES MGMT M/S 404 3000 ROCKEFELLER AVE EVERETT WA 98201-4046)
WATER AND SEPTIC SYSTEM INFORMATION
Is there an existing Well on the property? ❑Yes ✓❑No Is there an existing Septic System on-site? ❑Yes ✓❑No
Decommissioning of existing Well(s)and/or Septic System is required when connecting to city utilities
Is a Water Meter Required? ✓❑Yes ❑No
Water Meter Size Requested? ❑ 5/8" ❑ 1" ❑ 1.5" El 2" ❑ 3" ❑4" ❑ 6"
l hereby certify that the above information is correct and that the construction on,and the occupancy and the use of the above
described property will be in accordance with the laws,rules and regulations of the State of Washington.
°°"'9°e°e4"°`°"°m E Eric Nordstrom 5/27/2026
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Signature(owner/agent) Print Name Date
REV03.2022