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445 W 1st St Lot 5 - New Water Sew Tap Request t��tr!.' City of Atlantic Beach as v+ PUBLIC UTIUTIES DEPARTMENT A I c 902 Assisi Lane Jacksonville, FL 32233 \�,ji >r (904) 247-5834 NEW WATER / SEWER TAP REQUEST Date 11131 3I p2 Oa 3 Service Address LI k5 W Q 3-1' 4 SJr4 , Pte) FL 322 33 Cix4 ,5) Number of Units Commercial Q Residential ri7r. Multi-Family Q 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 Z©Ir I Z Q Prod a 110 (--( � � Billing Address 7a 0 Ti'� � Pd City A-b t-a Y1 TI C ?)-e C( CJ1 State P Zip-22 Phone (9o ) 3 2. 2 71 3 Email Z ()ff r f @ lyn P cov✓) Applicant Signature C-1( 191-1 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