129 DONNER RD NEW TAP REQUEST r'{1rL`l Gln
CITY OF ATLANTIC BEACH
PUBLIC UTILITIES
1200 Sandpiper Lane
ATLANTIC BEACH FL 32233
<D;319' (904)270-2535 or(904)247-5874
NEW WATER/SEWER TAP REQUEST
Date: 7- 5--= /6 Project Address: /27 /DnJi lt-7Z f&'9t0
No. of Units: / Commercial Residential t/ Multi-Family
t.
New Water Tap(s)&Meter(s) Meter Size(s) 3/t-/
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter_Size_New Connection to City Sewer
Name:
Applicant Address:
City: State: Zip
Phone Number: Cell Number:
Email Address Fax:
Signature:
(Applicant)
CITY STAFF USE ONLY
Application# ((p- SFA-T- /N9y
Water System Development Charge $ lV40, OQ O/)GY I l'VjVkC r7,^A
Sewer System Development Charge $44 OA-0 c) 0(41C. A,
Water Meter Only $ ✓/!aPrA�y,. SO is r4krQ
Reclaim Meter Only $ FpR o r �f Kn/175',
Water Meter Tap $ DO (nous)
Sewer Tap $
Cross Connection $ '5z.OD
Other $
TOTAL $/ny"�OVD,a_)APPROVED: Kavle Moore,PE
AA
(Deputy PW Director or Authorized Signature)
ALL TAP REQUEST MUST BE APPROVED BY UTLITIES DEPARTMENT BEFORE FEES
CANBEASSESSED