2205 Sandy Bay Ln UTIL18-0044 EICE1VlE UTTlt_ ( g- oogy
JUN 2 9 291 City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
BY- 1200 Sandpiper Lane
Atlantic Beach,FL 32233
(904)247-5834
NEW WATER/�SEWER TAP REQUEST
Date 6 -Zy'�9 Project Address o5 ?y t l-n .
Number of Units Commercial_ Residential Multi-Family—
New Water Taps)&Meter(s)� Meter Size(s) /�
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter_ A,t .Size New Connection to City Sewer
Applicant Name rU�t.J el,t.h ,n G. B vt t-oewq - tr-7G
Applicant Address 5615 H141tJ4 TElL� Some ?,ob
City TJIr *L-5Vfj tL.(A--- State_ zip 37,7-57
Phone q0+ - (9M -7533 Cell go4-- "5�?�05
r .
Email tn1 �. 0. 1+✓ VI �� .GvNI
Applicant Signature � � V P
. / CITYSTAFF USE ONLY
Application N Urn. /R — OoUY
Water
--
Water System Development Charge $_/r /410, 06
Sewer System Development Charge $ L U o 66
Water Meter Only
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection
Other $
TOTAL
$ cir y7, [ (Notes)
APPROVED Kayle Moore, P.E. �tr/� Date 9 Z c
Public Utilities Director or Authodzeosignatum
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED