1753 E PARK TER UTIL21-0001 r),..;,• City of Atlantic Beach
ri AA PUBLIC UTILITIES DEPARTMENT
A ,,,•'‘ PUBLIC
902 Assisi Lane
.).7'' V Jacksonville, FL 32233
x�,;t1�j;- (904) 247-5834
NEW WATER / SEWER TAP REQUEST
Date I - 7-2/ Service Address / 7S3 I g71,)/ �"kyt..4Gdr' �•45 T
Number of Units Commercial 0 Residential Multi-Family n
New Water Tap(s) & Meter(s)n Meter Size(s) 5/113
New Irrigation Meter Upgrade Existing Meter from to (size)
New Reclaim Water Meter I I Size New Connection to City Sewer El
Applicant Name AL, I Z 4 Aw-rz..--)1.5 On.)
Billing Address/ 75 3 �i9-/Lh/ 7;;L it c r L ,¢ST
City 477,/fi•r✓ri'6, &I*C,o-i State C� Zip 3 2 2 3 3
Phone ?O'/— 302 -31/9
Email A PGTm,so i ITS . TA)J. C o.y
Applicant Signature (itA .-(A.._ �-L- - --
CITY STAFF USE ONLY
Application # U I I L Z1 -0 001
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