23 CORAL ST NEW WATER/TAP s J� CITY OF ATLANTIC BEACH
PUBLIC UTILITIES
1200 Sandpiper Lane
ATLANTIC BEACH,FL 32233
(404) 270-2535 or(904)247-5874
NEW WATER/SEWER TAP REQUEST
Date: 7- Zr-/(a Project Address: 03 ��Z+4-� �5—F/4 ET
No. of Units: I Commercial Residential ✓ Multi-Family
New Water Tap(s) &Meter(s) V Meter Size(s)
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter Size New Connection to City Sewer
Name:
Applicant Address:
City: State: Zip
Phone Number: Cell Number:
Email Address Fax:
Signature:
(Applicant)
CITY STAFF USE ONLY
Application - SF2 - r'�fl�
1,l
Water System Development Charge $ / 1 q 0,CID —
Sewer System Development Charge $_ vtj e Cl << l lo
Water Meter Only $
Reclaim Meter Only $ r
Water Meter Tap $ ,bD -- �L 'N P t(n t )
Sewer Tap $
Cross Connection $ ,Sb, 08
Other $
TOTAL $ OLD
APPROVED: Kavle Moore, PE Jew.
(Deputy PW Director or Authorized Signature)
ALL TAP REQUEST MUST BE APPROVED BY UTLITIES DEPARTMENT BEFORE FEES
CAN BE ASSESSED