354 Seminole Rd UTIL19-0064 /'' City of Atlantic Beach
,Y U T I L 19-0 0 6 4 PUBUC UTIUTIES DEPARTMENT
:, , 902 Assisi Lane
> Jadcsonville,FL 32233
(904)247-5834
NEW WATER/SEWER TAP REQUEST
Date 7- .3-19 service Address 35-471 diva
Number of Units I Commercial Residential Multi-Family
New Water Tap(s)&Meter(s) Meter Size(s) ^7
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter Size New Connection to City Sewer
Applicant Name
Billing Address ,/ /n
fe714 f714t' o% Rcf) ,
City 41/ti M 7 C, 8 f G-6 A State /7- Zip 3 73
Phone 9 09- - 65 Z1— 'off Lt.
Email G S C \ `C e co m Cu541
I_ l�
Applicant Signature D obit, vu c-2u1
CITY STAFF USE ONLY
Application#21E5 *{ O/ *7 U t i 119-0064
Water System Development Charge $ Is /140, 0(6
Sewer System Development Charge $ LI. U . U�
Water Meter Only $
Redaim Meter Only $
Water Meter Tap $ WO
Sewer Tap $
Cross Connection $ 50
Other $
TOTAL $ . 040. () (Notes)
APPROVED �'`- `�— Date
Public Utilities Director or Authorized Signature
AU.TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED