HomeMy WebLinkAbout18005_Burn_Rd_Utility_Service_Connection_Application i
UTILITY SERVICE CONNECTION APPLICATION
,
Community and Economic Development
City of Arlington• 18204 59th 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: Water Only ❑ Sewer Only ❑ Water and Sewer
Occupancy: jq Single Family ❑ Duplex ❑ Multi-Family ❑ Commercial ❑ Industrial ❑ Institutional
Legal Property Address: 1 6 O05- 6UKW ,1,
Lot#: i Parcel ID Nos : 310619 - OO 1-006 " dv Subdivision:
Owner Name: AwQlr W t3 5T4- X_0 Office No.:
Email Address: &VA& Lu6f0.4A 6;^4gx.C"0^ Cell No.: i'filS`7570-36r8
Mailing Address: 0-16Ok 12k3 City: 4AAW(51/.'t-66�_ State: W.Z Zip: 9$27o
Owners Agent: lsw`vq� Office No.:
Email Address: e � C ` Cell No.: V - 76"
Mailin Address: P.O. 601V aIY3 city: /1.1A-l'Y5�-p-tis- State: L-A� zip:
GENERAL INFORMATION
Give a brief description of your proposal and/or request:
Tu0 I QAI 11 A P A T
t AdL 1 3 C14 /2- t ir c CW5!7Wr #o
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?2 5/8" ❑ 1" ❑ 1.5" ❑2" ❑3" ❑4" ❑6"
1 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.
V4
Signature(owner/agent) Print Name Date
REV03.2022