2223 Sandy Bay Ln Water/Tap u- -J -00a-
City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
MA9 2 2 2019 1200 Sandpiper Lane
r„-' Atlantic Beach, FL 32233
(904)247-5834
NEW WATER/SEWER TAP REQUEST
Date -3 I Z 2- t Project Address -,7, 2 2 3 St , 0. L A
Number of Units Commercial_ Residential Multi-Family_
d
New Water Tap(s)&Meter(s) Meter Size(s).A
New Irrigation Meter Upgrade Existing Meter from to (size)
II New Reclaim Water Meter— Size New Connection to City Sewer
Applicant Name_ _ t�Jabj / "T-L-�-nC hSL�lt'OE/L& ttr-jc .
ApplicantAddress__ 5�7t! HItJIf4 r -reAA+4'CC 5vtTE 'Lob
City__�tt �Vtl ux--- State Zip
Phone 00+ - (OS3 -153's Cell 104 -o805
Email tltvl Q,. �4rT'rlc. Vtide,/ .G-poM
Applicant Signature \j t
CITY STAFF USE ONLY
Application# UT!! 19 - 00 2/
Water System Development Charge $—h H0 , 00 SCANNED
Sewer System Development Charge $ UI]S� C� _ Dater
Water Meter Only
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection
Other $
TOTAL (Notes)
APPROVED � ��r� Date U' 22LY 9
Public Utilities Dire r arAutharizedSfgnature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED