meter JS r� City of Atlantic Beach
t� PUBLIC UTILITIES DEPARTMENT
902 Assisi Lane
Jacksonville, FL 32233
Vit?);• (904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date 1' V' 01() Service Address - ( 3 r Stir
Number of Units Commercial Fl Residential r7--- Multi-Family n
New Water Tap(s) & Meter(s)n Meter Size(s)
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter n Size / New Connection to City Sewer n
Applicant Name £t 'lei) e CI ( e rS
Billing Address 3 77
City State "F/• Zip 3 Zz3 3
Phone 70 - a y/- /effga
Email 4r/4 19(5-- /VEL •GGrVi
Applicant Signature
CITY STAFF USE ONLY
Application if
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