360 1st St WATER METER RELOCATE - City of Atlantic Beach
, .i.( '� PUBLIC UTILITIES DEPARTMENT
. _ 902 Assisi Lane
�JJacksonville, FL 32233
1: j (904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date r/1 / 2-e, 2-2— Service Address -->, 6 � / -_ IzE 4-#0741
. krx_c___ IA._
Number of Units Commercial r Residential Fr
Multi-Family n_
NewWater Tap(s) & Meter(s) Meter Size(s)
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter I I Size New Connection to City Sewer
Applicant Name D�V I P NE- L., /4.4.4 A:
Billing Address 4 L' / 5 ,t
City 1-0N--'- - -:: 2r State EG Zip a 3�
Phone 2e5 y 4/"." .7 - � (t'l, . -�E 2
Email cl 4J A) 17(e // // . G' ' 1'44 L b c.� fil !� !�
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