2757 Mayport Rd New Water/Sewer Tap Request far?..:y ;•1.i.;;-
t City of Atlantic Beach
.. ; ' PUBLIC UTILITIES DEPARTMENT
IC) 902 Assisi Lane
r' Jacksonville, FL 32233
(904) 247-5834
NEW WATER / SEWER TAP REQUEST
Lia•ze 9 ( LQ ( [ 1 Service Address 2-1 Si f o t
Number of Units I Commercial rvi Residential El Multi-Family Ea_
New Water Tap(s) & Meter(s)I I I Meter Size(s) 314
r.iew irrigation Meters Upgrade Existing Meter from to (size)
•
ew Reclaim Water M Size New Connection to City Sewer El
applicant Name C b I\byvU l
7 Ting Address \53 I U V---01
'ity State CP( Zip '51,233
none .1.v(A- -zi--,,/, - Lf2..1.43 J c-e - 51 1 - gY S5 3
'_mail
Applicant Signature vii
`�1r�-(\ l o HG n-n • ___ . ---- .__.
1 c CITY STAFF USE ONLY
Application # l ` L O O S 1 NO SEWElZ AJA I('q-i31e. 1
lite WOULD )4-AWE -
Water System Development Charge $ /, /'AD . oD �,-1,S f}0.- ,4. P.)°'1P_S.-VAT-10r)o ,
Sewer System Development Charge $ II Nsft-i- ZcC AAA-t fl QNtaea
Water Meter Only $ 014-Rcett IZD, 3
Reclaim Meter Only $
Water Meter Tap $ goo. 00
Sewer Tap $
Cross Connection $ 5o, o U
Other $
TOTAL $ 1, 9 go , co (N-=
APPROVED ^ t�--i 2_"jam Date . ,---4,Public Utilities Director or Authorized Signature
ALL TAP REQUESTS MUST BE APPROVED BY THE PUBLIC UTILITIES DEPARTMENT BEFORE FEES CAN BE AS5ESSEt;
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