251 LevyDate 4126123
Number of Units -3
City of Atlantic Beath
PUBLIC UTILITIES DEPARTMENT
902 Assisi Lane
Jacksonville, FL 32233
(904) 247-5886
NEW WATER / SEWER TAP REQUEST
Service Address 251 Leu
X
Commercial / Residential Multi -Family
New Water Tap(s) & Meter(s) Meter Size(s)
New Irrigation Meter Upgrade Existing Meter from to
New Reclaim Water Meter Size New Connection to City Sewer
Applicant Name
Billing Address
City
Phone
Email
Applicant Signature
Application #
Water System Development Charge
Sewer System Development Charge
Water Meter Only
Reclaim Meter Only
Water Meter Tap
Sewer Tap
Cross Connection
Other
TOTAL
APPROVED
State
CITY STAFF USE ONLY
$ 3 g a. 0
$ � 100
555, 0c)
$
I
Public tilities DirectororAuthorkedSigna ture
Zip
(size)
All fees must be paid before meter
set/establishing service,
Date _ �' '7 Z
"THIS IS AN APPLICATION ONLY. ONCE FEES ARE ESTABLISHED, PLEASE NOTIFY THE UTILITIES DEPARTMENT 1F YOU
WOULD LIKE TO PROCEED WITH THE PERMITTING PROCESS AND A PERMIT NUMBER WILL BE ASSIGNED TO THIS
APPLICATION.