1324 BEGONIA ST WATER APPLICATION City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
) 902 Assisi Lane
Jacksonville, FL 32233
(904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date \lJI 1 G 1 Service Address 2 l 3Cj \C _ \a -
Z233
Number of Units Commercial EI Residential Multi-Family IT
New Water Tap(s) & Meter(s) Meter Size(s)
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter n Size New Connection to City Sewer
Applicant Name El G1 1 20(\i,coo
Billing Address do c\rwi`
City Vti MO -i\`1 StateO
` Zip02- Iq 0
Phone C 51 OS 2—
Email
Email eiCi(1nc, `( • c \OC\O 0Thoo . C6M
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