2135 SEMINOLE RD UTILITY City of Atlantic Beach
PUBLIC UTILITIES DEPARTMENT
902 Assisi Lane
Jacksonville, FL 32233
(904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date 61//01/2-0 Service Address o9-I36 36 ce Yte le_ PA
Number of Units Commercial U Residential IX 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
1 � / 1
r
Applicant Name Gil:91 %Na., Vv Ol,\ C s
Billing Address ,2--kS€.w vldt€ �� •
City ACtfrdt TLC State Zip 322.33
Phone 9.00r- ! l 72 1 c - `-7 9011 - (05 (1 — g581
Email riF1 ye6 bJIcxvbiricj . C.O/
Applicant Signature
CITY STAFF USE ONLY
Application #
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