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HomeMy WebLinkAbout20260408_PJA26-0197_App Q#J . 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: fZ Single Family ❑ Duplex ❑ Multi-Family ❑ Commercial ❑ Industrial ❑ Institutional Legal Property Address: 2,0 71 ( S i-4cj tz k PG)'i1 61 v,:,l /.A `1 2-3 Lot#: ParcellDNo s : 3/o5agaol-loo6©G Subdivision: Owner Name: /y/ Office No.: Email Address: hc_X�v• )- Cry1v / Cell No.: `12-5 3g7 77l3 MailingAddress: �711 S� ^� �{y ��'^ ��v City: �y/�N �'H State: �� Zi `�,�1ZZ3 Owners Agent: Office No.: Email Address: Cell No.: Mailing Address: city. State: Zip: GENERAL INFORMATION Give a brief description of your proposal and/or request: WATER AND SEPTIC.SYSTEM INFORMATION Is there an existing Well on the property? 1Z 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" ❑ 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 proper t e i accordance with the laws,rules and regulations of the State of Washington. Xa,/ ey� n re(owner/agent) Print Name Date' REV03.2022