835 Atlantic Blvd UTIL19-0046 City of Atlantic Beach
z+� PUBLIC UTILITIES DEPARTMENT
`? 902 Assisi Lane
"~ Jacksonville, FL 32233
(904) 247-5834
NEW WATER/ SEWER TAP REQUEST
Date j, �� ��d lq Service Address g�j" /�"t(s '�'`�- 8k,)cJ 2 Z33
Number of Units Commercial EEC Residential Q_ Multi-Family®_
New Water Tap(s) & Meter(s)Er Meter Size(s)
New irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water-Meter�— Size New Connection to City Sewer Q_
Applicant Name rC3 ��� (3�C ��c� �-- S�-vv Jj b(e
Billing Address e 5 I rc 4""
City State �-- Zip-3 2 23?
Phone C7_
Email �� X 4C rt2 s > c o.W
Applicant Signature
CITY STAFF USE ONLY
Application# _ ��
Water System Development Charge
Sewer System Development Charge $
Water Meter Only $ -
Reclaim Meter Only $ _
Water Meter Tap $ g 5 OU
Sewer Tap $
Cross Connection $ X56 , co
Other $
TOTAL $ 20 7 92_ f'o I (Notes)
APPROVED Date 7- 9-Z 9
Pub Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED