1657 MARITIME OAK DR - UTILITY , r
RECEIVED
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City of Atlantic Beach
�` ECEiR PUBLIC UTILITIES DEPARTMENT
NQS'. z it' I ;, �',. '�rI1
3" r' 902 Assisi Lane
\'J NOV 8 201$ Jacksonville, FL 32233
Building z,: '- ' ent (904) 247-5834
City of Atlantic Beach, FL BY:___
NEW WATER / SEWER TAP REQUEST
Date /1 r/ X Service Address /6 C 7 /4//17 f CC,/ Ck_
Number of Units Commercial Residential Multi-Family
New Water Tap(s) & Meter(s) X Meter Size(s)
New Irrigation Meter Upgrade Existing • - - •m to (size) I_
New Reclaim Water Meter Size New Connection to City • . •r = C)'ld Ue m�tV S
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Applicant Name g'tie(5 �J01 S (61(i- Cl /.50,11),vis
Billing Address 1,91-).-7(4(D San -Tosc bud S ilk 0-4,
City J;( S-on U'((c State I Zip 1;;-2-3
Phone 90 - SS- 4 (2, s----
Email AA-d/e✓6) /YI /1l'C/s7 ` CO/Yt
Applicant Signature
CITY STAFF USE ONLY
Application# (-MIL_ i b - Q v(o
Wioe..44-TE- 1114elt le 2-
Water System Development Charge $
Sewer System Development Charge $
Water Meter Only $
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection $
Other $ 7 ,e, (O
TOTAL $ 704 (Notes)
APPROVED � Date //-9'fp"
>,L4( 3C---&_
blic Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED