HomeMy WebLinkAboutApplication . �y CTION APPLICATION
UTILITY SERVICE CONNE
Community and Economic Development
551
_ 59
th Avenue NE • Arlington, WA 98223 • Phone (360) 403 3
City of Arlington • 18204
Submittal Requirements:
1. Complete Application
2. 81/2
_ PP 11" Site Plan/Sketch of the Proposal meter installation
3. Payment and Permit issuance is required prior to water
�, Water Only � Sewer Only ❑ Water and Sewer
Type of Request:
❑Famil ❑
Commercial ❑ Industrial ❑ Institutional
Occupancy: ❑ Sin le g y Duplex ❑ Multi-Family
Legal Property Address: Subdivision:
Lot #: Parcel ID Nos
Office No.:
Owner- Name:
t Cell No. �
_7r
Email Address: m<c t. �ti Zi `
State:
Mailing Address: A
2l„
- Office No.:
Owners Agent: � '""
Cell No..
Email Address: Zip:_
Ci State:
N4-�;l ra .Address:
. .. .:::::::::::::..................
GENERAL INS MATION
Give a brief description of your proposal and/or request: ,
WATER AND
SEPTIC SYSTEM INFORMATION
I there an existing Well on the property? ❑ YesE4No Is there an existing Septic System on-site? 0YesPqN0
s g
Decommissioning of existing Well(s) and/or Septic System is required when connecting to city utilities
Is a Water Meter Required? NYesF]No
Water Meter Size Requested? /8" ❑ 1" ❑ is) ❑ 2" ❑ 3" ❑ 4" ❑ 6"
7
I 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.
l 1
Signature (own +/agent) Print Name Dat
REV03.2022