1251 SELVA MARINA CIR - UTILITY UqllI8 — ( O (
ECEIVEU
City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT NOV 3 2018 902 Assisi Lane
Jacksonville, FL 32233
.;„ BY: (904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date g,,I I 2✓ l Service Address I Z S ( Ste( Mar(AA
Number of Units Commercial Residential X Multi-Family
New Water Tap(s) & Meter(s) Meter Size(s)
New Irrigation Meter Ix Upgrade Existing Meter from to (size)
New Reclaim Water Meter /� Size New Connection to City Sewer
oApplicant Name JJ 6 v c n< c
Billing Address \ 25- I Sc_ I Ja M a r,tea C , r c lc
City ���� (Drink State F�
REttIV
Phone 9 0 `I. 6 «.S y o
CIVED
Email is- 5 6,1A «L as. NOV 1 9 2018
Applicant Signature Building Department
of " 7 - —'T—
CITY STAFF USE ONLY
Application# UT/L 18 r 00(07
Water System Development Charge $ I Qo O --
Sewer System Development Charge $
Water Meter Only $ 220 , 00
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection $ 1/45-0
Other $
TOTAL $ 2 /7 . 00 (Notes)
APPROVED P Date
Utilities
Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED