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445 W 1st St Lot 6 - New Water Sewer Tap Request 0 ,4 City of Atlantic Beach \to PUBLIC UTILITIES DEPARTMENT • • A Is 902 Assisi Lane ppiZ Jacksonville, FL 32233 y !3 S>1 (904) 247-5834 NEW WATER / SEWER TAP REQUEST Date 8 Ige123 Service Address -1 t 5 Q• I $ Sk ) A , FL 3 V 33 Number of Units Commercial fl Residential Multi-Family r _ \ G)' New Water Tap(s) & Meter(s)[171/ Meter Size(s) New Irrigation Meter Upgrade Existing Meter from to (size) New Reclaim Water MeterI I Size New Connection to City Sewer Applicant Name -ZO1 1% 2Gt. Pr da r7d Billing Address 720 ! r-14-ori Rd City Y7-1-LaWt4 i C bectdN State F L Zip 32233 Phone ( o ) J U — l l ).) Email z_orrin p@ C© VVI Applicant Signature c� ` 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