1420 Mayport Rd UTIL19-0034 Unit 3 04( ( lq - oo.31
City of Atlantic Beach
s; PUBLIC UTILITIES DEPARTMENT
r r�
902 Assisi Lane
j Jacksonville, FL 32233
(904) 247-5834
U1119
NEW WATER / SEWER TAP REQUEST
1 n 20 RA43
Date HAI 2 20(9 Service Address i�d_ M 4`1 P6ET
Number of Units Commercial Residential Multi-Family
New Water Tap(s) & Meter(s) Meter Size(s)_ �y
New Irrigation Meter Wo Upgrade Existing Meter from to (size)
New Reclaim Water Meter Size New Connection to City Sewer
Applicant
Name M i KE l,% 444 L tom'
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Billing Address
I --)Ao AM-W —7 2v�
City
State — Zip .�e
Phone `7 t)q- 2LR3.30? (WK�
Oc-/- (oLg_- /V6.5 G PI
Email S EC.I 'L7 /t'1 +R.DI 0 .J^W D UTE
47 k 'IL-5 -1 Nai A
Applicant Signature "
Al 0"n1 5 i{ 2 � Sri
CITY STAFF USE ONLY
Application#t
Water System Development Charge
Sewer System Development Charge --- -
Water Meter Only $- ------- —
Reclaim Meter Only $ --
Water Meter Tap $ '
Sewer Tap $
Cross Connection $ --�-�
Other $ /meq
TOTAL $ ! !�► a (Notes)
APPROVED - Date ��~7• ��
P lic Utilities Director or AVthorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED