1420 Mayport Rd UTIL19-0033 Unit 2 U+ I ( I- 06 3
fy J City of Atlantic Beach
!� PUBLIC UTILITIES DEPARTMENT
r� 902 Assisi Lane
Jacksonville, FL 32233
sirs S9 (904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date MAY 2 ;2,0(9 Service Address All-- IkI dET „UA-D
Number of Units 1 Commercial Residential Multi-Family
New Water Tap(s) & Meter(s) Meter Size(s).
New Irrigation Meter WD Upgrade Existing Meter from to (size)
New Reclaim Water Meter Size �_ New Connection to City Sewer
Applicant Name P I rE t 444L E7%; �S,Az-c 1, az V4,P-a,L�
Billing Address 14;Lo /Ll,4'-1�WT 2'yM
City I—L 6241 State _ zip _322--Z3
Phone `7 o - 2LR-3.3CL? WK')
Gty- 63-47- /065' �
Email S jO&C.l.ALT-1 Al 40e DZ t- 7J)0 " � I�-1
i t if i7s . �5 N 67' A
Applicant Signature ' �/V" l !)U,0L.:IZ4jL
1 I q CITY STAFF USE ONLY
Application#
Water System Development Charge
Sewer System Development Charge $
Water Meter Only
Reclaim Meter Only $
Water Meter Tap goo, d
Sewer Tap
Cross Connection
Other $ _
TOTAL $ �j ��t (Notes)
APPROVED - c. Date S- 7-1 9
Pub Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED