Civ20-0004 City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
902 Assisi Lane
Jacksonville, FL 32233
(904) 247-5886
NEW WATER / SEWER TAP REQUEST
Date ________________Service Address __________________________________________________
Number of Units _____ Commercial _____ Residential _____ Multi-Family _____
New Water Tap(s) & Meter(s) _____Meter Size(s) __________
New Irrigation Meter _______ Upgrade Existing Meter from ___________ to ___________ (size)
New Reclaim Water Meter _____ Size _______ New Connection to City Sewer _____
Applicant Name ___________________________________________________________________
Billing Address _________________________________________________________________
City ______________________________________State __________Zip ______________
Phone ____________________________________
Email _______________________________________________________________________
Applicant Signature ____________________________________________________________
CITY STAFF USE ONLY
Application # ________________________
Water System Development Charge $_____________________
Sewer System Development Charge $_____________________
Water Meter Only $_____________________
Reclaim Meter Only $_____________________
Water Meter Tap $_____________________
Sewer Tap $_____________________
Cross Connection $_____________________
Other $_____________________
TOTAL $_____________________ (Notes)
APPROVED Date __________________
Public Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED