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DECE[VE City Of Atlantic Beach
n OCT 15 2018 12 Sa dpiper LanePARTMENT
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P ' 1 Atlantic Beach,FL 32233
�'-- -- (904)247-5834
NEW WATER/SEWER TAP REQUEST
Date 10 L"115 Project Address ?- / '5 a 0-1 3� Cs4- JC,
Number of Units I CommercialResidential f
Multi-Family_
New Water Tap(s)&Meter(s) 3 d
Meter Sizes)
New Irrigation Meter Upgrade Existing Meter from
to (sue)
New Reclaim Water Meter_ A 'Size New Connection to City Sewer_
Applicant Name "J 11-�1.,/ c- B� ,
y Ir�.1G
Applicant Address_ rj 87S ("'�l/Jt�G jj 2l � 5L!I'TE 2066,
city-. ZQkC44'' 1.Jgll.(.G
State._ ZIP zz-5
Phone _ �01" — 6,S3 --7533 Cell_ qOa}- �s}!j ogpCy,
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Email lrq. Q, latrt'i vi1lden .coat
Applicant Signature
VI
CITYSTAFF USE ONLY
Application p L�_J L 1 8 - OD 5 9
Water System Development Charge S Q, (�
Sewer System Development Charge 5 (SQ--
Water Meter Only S t__R
Reclaim Only $
Water Meter Tap
Sewer Tap S
Cross Connection
Other S
TOTAL S
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APPROVED 6, E
Public
Date
Utllities D/ ororAuthorlzedSfgnoture Q
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED