884-886 East Coast Dr UTIL19-0019 New Water/Sewer Tap tr,ir
MAR 2 2 2019 City of Atlantic each
PUBLIC UTILITIES DEPARTMENT
902 Assisi Lane
Jacksonville, FL 32233
/ `i y, (904) 247-5834
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NEW WATER / SEWER TAP REQUEST
Date J;v� / l Service Address Cl(�
Number of Units Commercial Residentialy Multi-Family
New Water Tap(s) & Meter(s) Meter Size(s)
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter Size New Connection to City Sewer
Applicant Name 02d /-/,I -r'
Billing Address j '✓ C !/�� Q 4/X,14
Cit / IG
Y State L Zip
Phone 7 Gf/
Email
Applicant Signature
CITY STAFF USE ONLY
Application #(.SIL P9 - 00117 ("01toCo r." Z3,1 E- Lov d,
Water System Development Charge $ d0
Sewer System Development Charge $
Water Meter Only $ CZ
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection $
Other $
TOTAL $ S, ��� (Notes)
APPROVED Date
ublic Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED