HomeMy WebLinkAbout20260316_PJA26-0151_App and Site Plan UTILITY SERVICE CONNECTION APPLICATION
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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: ❑ Water Only 0 Sewer Only ❑ Water and Sewer
Occupancy: X Single Family ❑ Duplex ❑ Multi-Family ❑ Commercial ❑ Industrial ❑ Institutional
Legal Property Address: o C, C =y tit, S
Lot#: Parcel ID Nos : Subdivision:
Owner Name: QL.(9 7b)Iv t3NI_nG;p C_`1AcsQ rA+ Office No.:
Email Address: (C_&:_� Cell No.:
Mailing Address: R o city: t w w_-eb*t State: V A Zip:
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: QW11 Qc C Ac A _ r# ec:v C_
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WATER AND SEPTIC SYSTEM INFORMATION
Is there an existing Well on the property? ❑Yes ZNo Is there an existing Septic System on-site? Des [E]No
Decommissioning of existing Well(s)and/or Septic System is required when connecting to city utilities
Is a Water Meter Required? Des 5No
Water Meter Size Requested? ❑5/8" ❑ 1" Ells, ❑2" ❑3" ❑4" ❑6"
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.
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Signature(owner/agent) Print Name Date
REV03.2022
ArLington United Church
Sewer Line Repair Project Spring/Summer 2026
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