586 Timber Bridge Lane WATER/TAP REQ City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
902 Assisi Lane
Jacksonville, FL 32233
(904) 247-5834
NEW WATER / SEWER TAP REQUEST U -TI (_ ( 9 --0007
Date Service Address 5 (p 11tY\C_ ,� b V ICA Yl.R-
Number of Units y Commercial Residential Multi-Family 6- (<C,141 m
d rilrC y(
New Water Tap(s) & Meter(s)_[_ Meter Sizex Oofi o-fs)
New Irrigation Meter Upgrade Existing Meter from IY1L�'� to (size L
New Reclaim Water Meter Size New Connection to City Sewer �T
Applicant Name RIU�'f� I,nn1S
Billing Address ���, (p JuY� lose_
City 'TOC. --,,nn V State l I zip
Phone a 6 q agi7 - (o X01 S
Email Uledci JerSi`� o
Applicant Signature
CITY STAFF USE ONLY
Application# (lTw_ 1 - Oc)O 7
Water System Development Charge $ �
Sewer System Development Charge $
Water Meter Only (,Zle�
$
Reclaim Meter Only (pC4a`T7r_ ) $ 3,5D, CIO
Water Meter Tap $
Sewer Tap $
Cross Connection $
Other $
TOTAL C-10 (Notes)
APPROVED Date Zd 'rcj
ublic Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED