2028 Mealy Lane New Water/Tap UT( L l 8 - 0009
City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
.r" 902 Assisi Lane
Jacksonville,FL 32233
(904)247-5834
NEW WATER/SEWER
��TAP REQUEST
Date S Service Address aoaV Mr Oal- y Lavwo-
Numberof Units Commercial_ Residential ✓ Multi-Family_
New Water Tap(s)&Meter(s)_ Meter Size(s)
New Irrigation Meter I Upgrade Existing Meter from -- to (size)
New Reclaim Water Meter_,, , ,Size New Connection to City Sewer
Applicant Name O _f, y Ouc) .YYL,S ✓t
,O
Billing Address 4 angt W tYl(.xY✓�f-e ✓r
city State r� • Zip
Phone 1IC1��' ZZ2-IZ32
Email HeGf'lTer . rRJ�CY1YtSOY\ C114b¢.COY`1
Applicant Signature
i
CTTYSTAFF USE ONLY
Applicationq 1����- o�3z- 3 �
/y aMt�n.
Water System Development Charge $�t I LID, oo<<�• )
Sewer System Development Charge $
Water Meter Only $
Reclaim Meter Only $
Water Meter Tap $_ 00,00
Sewer Tap $
Cross Connection $ 6X) �0o
Other $
TOTAL $ - ,/ /.� (Nates)
APPROVED Com../✓�� Date �z�
Public Ut ides DimctororAuthorlred S,gnature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED