1300 Seminole Rd UTIL19-0066 water fountain meter request City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
i
- 902 Assisi Lane
Jacksonville, FL 32233
(904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date Service Address 76/14+' 5Qgl 7AZt--
Number of Units Commercial Residential 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
Billing Address
City State Zip
Phone
Email
Applicant Signature
CITY STAFF USE ONLY
Application #
IRS + 61,ert'-)Z rZcC�i�/t7�
tAj
Water System Development Charge $_�,
Sewer System Development Charge $
Water Meter Only $
Reclaim Meter Only $
Water Meter Tap $ g�• Od
Sewer Tap $
Cross Connection $ '-f-y-) , oU
Other $
TOTAL $ �, 9 9�, ad (Notes)
APPROVED (_ �u- Date /O - 2
Pubijebtilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED