Landscape_Sprinkler_Permit_ApplicationLANDSCAPE SPRINKLER PERMIT
FOR BACKFLOW PREVENTION ASSEMBLY INSTALLATION
425-771-0235, EXTENSION 1644, FAX 425-744-6057
PURPOSE: TO PROTECT THE DRINKING WATER SUPPLY!
To insure potential contaminated water will not re-enter into the drinking water supply system.
'I)c Y s9.r
Edmonds Department of Parks, Recreation,
PROPERTY OWNER / BUSINESS NAME: and Cultural Resources, Attn: Shannon Burley
SERVICE ADDRESS: 310 6th Ave N, Edmonds, WA 98020 PHONE:
MAILING ADDRESS: 700 Main St, Edmonds, WA 98020
y CONTRACTOR:
MAILING ADDRESS:
PHONE:
425.771.0230
DATE APPLIED: 03/13/2020 PERMIT FEE: NO CHARGE
PLEASE ATTACH DRAWING OF PROPOSED SYSTEM SHOWING POINT OF CONNECTION TO WATER SYSTEM
AND BACKFLOW PREVENTION ASSEMBLY LOCATIONS
PUT A CHECK NEXT TO TYPE OF ASSEMBLY YOU ARE INSTALLING FROM THE LIST BELOW
CHECK BOX
Double Check Valve Assembly DCVA)
x
Double Check Detector Assembly DCDA
Reduced Pressure Principal Assembly RPBA
Reduced Pressure Principal Detector Assembly RPDA
Pressure Vacuum Breaker Assembly PVBA
Atmospheric Vacuum Breakers) (AVB) (No test Required
NOTE: (Step procedures below)
1) ALL INSTALLED BACKFLOW PREVENTION ASSEMBLIES CONNECTED TO THE CITY OF EDMONDS WATER
SUPPLY MUST BE PROPERLY INSTALLED AND SHALL BE MODELS INCLUDED ON THE CURRENT LIST OF
BACKFLOW ASSEMBLIES, APPROVED FOR INSTALLATION IN WASHINGTON STATE.
2) THE CITY'S CROSS -CONNECTION CONTROL INSPECTOR MUST DO A VISUAL INSPECTION BEFORE YOU
HAVE ASSEMBLY TESTED. TO MAKE INSPECTION APPOINTMENT CALL 425-771-0235, EXTENSION 1644 AT
LEAST 24 HOURS IN ADVANCE.
3) ASSEMBLY TESTING MUST BE DONE BY A STATE CERTIFIED BACKFLOW ASSEMBLY TESTER AT THE
TIME OF INSTALLATION, AFTER REPAIRS, RELOCATION OF ASSEMBLY, AND ANNUALLY THEREAFTER.
4) TESTER SHALL FORWARD ALL PERMITS AND BACKFLOW ASSEMBLY TESTS REPORTS TO THE
EDMONDS WATER DIVISION ATTENTION JEFF KOBYLK AT 7110 — 210T" ST SW EDMONDS, WA 98026 OR
FAX THEM TO 425-744-6057. FAILURE TO COMPLY MAY RESULT IN TERMINATION OF WATER SERVICE TO
PREMISES.
PERMIT EXPIRES 90 DAYS AFTER DATE OF ISSUANCE
FOR OFFICE USE ONLY
PLAN APPROVED BY:
DATE FIELD INSPECTION DONE:
DATE ASSEMBLY TEST RESULT RECEIVED:
DATE OF FINAL APPROVAL:
Wordata/Water/Forms/Landscape Sprinkler Permit 2006