42 11TH ST - WATER & SEWER TAP F r °'' CITY OF ATLANTIC BEACH
tF+ ;= ` r 1r) PUBLIC UTILITIES
o:
1200 Sandpiper Lane
ATLANTIC BEACH, FL 32233
�f f (904) 270-2535 or (904) 247-5874
NEW WATER/SEWER TAP REQUEST I — P Le – 3(00-
Date: ,3–27 17 Project Address: `/Z /1 S Z—E7
No. of Units: I Commercial Residential ✓ Multi-Family
New Water Tap(s) & Meter(s) Meter Size(s)
New Irrigation Meter Upgrade Existing Meter from `3A/ • to I " (size)
New Reclaim Water Meter Size New Connection to City Sewer
Name: Gres Beli les
Applicant Address: 1-V2_ 11+11 S+e--
city: Ai\a C Bata\ State: FL Zip 32?-33
Phone Number: Cell Number: 132.486,1213
Email Address Fax:
Signature:
(Applicant)
CITY STAFF USE ONLY
Application#
Water System Development Charge $ '74
Sewer System Development Charge $ g 7i Li.(x)
Water Meter Only $ 35, 00
Reclaim Meter Only $
Water Meter Tap $ (notes)
Sewer Tap $
Cross Connection $
Other $
TOTAL S
APPROVED: Kavle Moore, PE
(Deputy PW Director or Authorized Signature)
ALL TAP REQUEST MUST BE APPROVED BY UTLITIES DEPARTMENT BEFORE FEES
CAN BE ASSESSED