1024 MAIN ST - REQUEST / /f,,
CITY OF ATLANTIC BEACH
41 i' PUBLIC UTILITIES
1200 Sandpiper Lane
ATLANTIC BEACH, FL 32233
(904) 270 -2535 or (904) 247 -5874
NEW WATER/SEWER TAP REQUEST
Date: /- /3 - !(v Project Address: ( u a 4-
No. of Units: 1.- Commercial Residential x Multi - Family
New Water Tap(s) & Meter(s) x Meter Size(s) i4j p, S'fj-� .J i Z- c
New Irrigation Meter Upgrade Existing Meter from to (size)
New Connection to City Sewer x
Name: RPO (rwit aI rim-I-map Y S, In c
Applicant Address: ?4$ (Lvy 'd
City: 6ccd.1t State: EL_ Zip: 3P-233
Phone Number: _ 90 ti- at/I - tfg &L Cell Number:
Email Address je1iy)14r , rp ,/ , ezm Fax: got/ -7 yq,2 7
Signature:
(Applicant)
CITY STAFF USE ONLY
Application#
Water System Development Charge $_
Sewer System Development Charge $
Water Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection $ _
Other $
(notes)
TOTAL $
APPROVED:
(Utility Director or Authorized Signature)
ALL TAP REQUEST MUST BE APPROVED BY UTLITIES DEPARTMENT BEFORE FEES
CAN BE ASSESSED