145 8th St UTIL19-0055 Water/Sewer J
0 6 SS
City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
902 Assisi Lane
i Jacksonville, FL 32233
(904)247-5834
NEW WATER / SEWER TAP REQUEST
Date 0� Service Address /`J 5 'P+' TR EE T
Number of Units Commercial Residential +� Multi-Family
(I
New Water Tap(s) & Meter(s) ® 02s,
Meter Size(s)
New Irrigation Metery Upgrade Existing Meter from to (size)
New Reclaim Water Meter Size New Connection to City Sewer
Applicant Name S�FrR � - -�� S LLF_.s
Billing Address I y 5 �44,, S ►" -e
City -t��-FI'G a C 6 State `�L zip 2 2 3
Phone ( IDy
Email JEFF RE`( �Sa= LI.E�S acv �lA 1 r` C Olv1
Applicant Signature
CITY STAFF USE ONLY
Application# C) SCJ
Water System Development Charge $ I LI(3 , CD
Sewer System Development Charge $
Water Meter Only $
Reclaim Meter Only $
Water Meter Tap $ Roo, DD
Sewer Tap $
Cross Connection $ -50 1 UO
Other $
TOTAL $ 1' 'qR c) , oD (Notes)
APPROVED Date 9
Publi Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN.BE ASSESSED
J~
•
sh Register Receipt Receipt Number
City ofAtlanticBeach R9830
DESCRIPTION ACCOUNTCITY PAID
PermitTRAK $1,990.00
UTIL19-0055 Address: 145 8TH ST APN: 170323 0000 $1,990.00
PUBLIC UTILITIES $1,990.00
CROSS CONNECTION 400-0000-343-3701 1 $50.00
WATER METER AND TAP 400-0000-343-3302 0 $800.00
WATER SYSTEM DEVELOPMENT IMPACT 415-0000-324-0301 1 $1,140.00
CHARGE
TOTAL FEES PAID BY RECEIPT: R9830 $1,990.00
Date Paid:Tuesday, August 13, 2019
Paid By: SELLERS JEFFREY B
Cashier: CT
Pay Method: CREDIT CARD 05011G
Printed:Tuesday,August 13,2019 10:42 AM 1 of 1 �
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