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City of Atlantic Beach
DECE'VE3f1t} PUBLIC UTILITIES DEPARTMENT
11 ne
OCT 15 2018 11 Atlanttic Beach,rFIL 32233
' t y (904)247-5834
BY• —
NEW WATER/SEWER TAP REQUEST
DateIb ( (g Project Address Z(m) 3 $AN0 1 aA-1 LhJJjg�
Number of Units Commercial_ Residential V/ Multi-Family_
New Water Ta &Meter 'j r
Tap(s) (s) Met
� er Size(s) /_
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter_ Size New Connection to City Sewer
Applicant Name b49tJ Ai—t,—An ,nc- Tj V r C.QgLs y yr„lc,
Applicant Address 7677 Hi.-JwG T /11LAli SVt-r� lob
City- :J;S! k fjgt State Zip ZZr77
Phone qq4 " $3 -7,y1533 t Cell__904— S�i
Email t(Ot`t C. 'Qrl l l Vi ld ,G.oM
Applicant Signature
i
CITYSTAFF USE ONLY
Application N Ur) L I R -
Water System Development Charge $
Sewer System Development Charge $
Water Meter Only $
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection $ rt�T-
Other $
TOTAL
$ S Z
(Notes)
APPROVED K:W!'ClgwrrE, t 1 �--� Date �Q-/g—
PublicVtilities0/7oror uthodzedsignowre
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED