1725 Beach Ave New Water/Sewer Tap Request rrs r ji„,rt�, City of Atlantic Beach
it PUBLIC UTILITIES DEPARTMENT
.. L':,.-;?)
=) 902 Assisi Lane
0 v~ Jacksonville, FL 32233
?..401119`," (904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date 5/is Service Address / 7,26 3c4ieh. AJL
Number of Units .2 Commercial ® Residential F( Multi-Family 1 'i_
4a
New Water Tap(s) & Meter(s) Meter Size(s) It
New Irrigation Meter Upgrade Existing Meter from -344 to I 1( (size)
New Reclaim Water Meter Size New Connection to City Sewer
Applicant NameApt....,,,,, 5cry tirN,c_A—s
Billing Address 660 Po -V S-€
City w�tC, 5 0n N../LL I C.) State 1-1,... Zip ad
Phone g(3 ( 7 70
Email a.M _, cell, .g . (OU I 1 - , �,o.M
Applicant Signature - �f -
I
CITY STAFF USE ONLY
Application It
Water System Development Charge $
Sewer System Development Charge $
Water Meter Only $
Reclaim Meter Only $
Water Meter Tap $
Sewer Tap $
Cross Connection $
Other $
TOTAL $ (Notes)
APPROVED Date
Public Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE ASSESSED