920 MAYPORT RD - WATER/SEWER TAP SHEET ri��lyl
J CITY OF ATLANTIC BEACH
r' PUBLIC UTILITIES
1200 Sandpiper Lane
ATLANTIC BEACH,FL 32233
(904)270-2535 or(904)247-5874
NEW WATER/SEWER TAP REQUEST
Date: 'j- ZZ — /7 Project Address: 49
No.of Units: Commercial ✓ Residential Multi-Family
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
Name:
Applicant Address:
City: State: Zip
Phone Number: Cell Number:
Email Address Fax:
Signature:
(App/ltoM)
CITY STAFF USE ONLY
Application# Z,s Cvra- 990
Water System Development Charge $ iy.Mw
Sewer System Development Charge $ , [91
Water Meter O Only $
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $ (notes)
Cross Connection $ y�
Other $
TOTAL $ �
APPROVED: Kavle Moore.PE
(Depury PW Diredw w AuthwiredS1gnMre)
ALL TAP REQUEST MUST BE APPROVED By UTLITIES DEPARTMENT BEFORE FEES
CANBEASSESSED