1719 BEACH AVE - UTILITY UT v g- O05 (
City of Atlantic Beach
CEIPUBLIC UTILITIES DEPARTMENT
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4 !�, 902 Assisi Lane
a JUL 3 �1� ( Jacksonville, FL 32233
2 (904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date ; / Service Address 17)9 I,C AC-11
Number 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 I C Size New Connection to City Sewer
Applicant Name 1 ` `�L! M J L V—(-J.
Billing Address / 7 /7 RL A U�
City AT-LA c { State 800 r PA- Zip 3 ZZ...3
Phone cicg9 c _ 7 g S-
Email i3'1(.t--1_ • (2.-IC ' Aa►'Yl A I L
Orlir, 111111r
Applicant Signature
I/
CITY STAFF USE ONLY )
Application # /L /' - 00 5/ TIS 5 IS •Fot A 3"nntTcrZ
Water System Development Charge $ i� / t4 v� V
Sewer System Development Charge $
Water Meter Only $
Reclaim Meter Only $
Water Meter Tap $ f3ot , DC7
Sewer Tap $
Cross Connection $ (5-0, QCT
Other $ Q COTOTAL $ 't [ ''U . 1O (Notes)
APPROVED Kayle Moore, P.E. X Date f-/2-/C
Public Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED