2253 Sandy Bay Lane GoAA g)
L) TILt g - OOS8,
ECEIVE City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
OCT 15 2018 1200 Sandpiper Lane
Atlantic Beach, FL 32233
(904)247-5834
NEW WATER J SEWER TAP REQUEST
Date /V r o /it Project Address 22.5 3 S A'+ Pt l !3kJ
kJ
Number of Units I Commercial_ Residential Multi-Family_
3
New Water Taps)&Meter(s)--Z- Meter Size(s) It
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter_I ,1 .,Size New Connection to City Sewer
Applicant Name PJEW A j,-h.. *n c— 6,d euty ytr1 C..
Applicant Address 15,615 MInJIt44 T -aA4Cc 5vITE lob
City
State Zip ZZ�l
Phone 010+ — $3 -7533 Cell of o4
Email I twt e.. t4 lc VI IA. P .C,.oN1
Applicant Signature
CITYSTAFF USE ONLY
Application k GTI ( Ann 5 9
Water System Development Charge $ 1 t-l1.. , yo
Sewer System Development Charge $ , c3n
Water Meter Only $ 1RS, Fin
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection
Other $
TOTAL $ YZS t�U (Notes)
APPROVED Jtwl +-c Date
Public Utilities Dire rorAuthodzedSignatum
ALL TAP REQUESTS MUST BE APPRO 0 BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED