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R% COMM ST'LUCIE COUNTY UTILITIES: P O.BOX"728,FT PIERCE,-FL 34982
RES
SEWER NAME
METER SZ
SECURITY""DEP SERVICE ADDRESS ���� - a�
I
SERVICE FEE I
1 ,
.:SAME DAY FEE
SUBDMSION
LOT, -a BLOCK
I .
:OVERTIME FEE
METER INSTALL BILLING�►DDRESS
FPUA CFC � 0 MOVE IN/CLOSING DATE 1
. CFC/SEWER
This application hereby request and;authorizes the,Utility to=render water and/or sewage disposal
GUAR::REV. seivices;toahe"premises described,above maccordance with the Utilities present:or!future rates,
LATERAL, rules and regulations,which by reference are made a part of this fcontract Apphcantagreesto pay
(� the Uhhty;promptly for,such services m accordance w�th'the established rules and regulations.
$ "1' TOTAL CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE
CUSTOMER SOCIAL SEC/ I <
SIGNATURE "�s "' FED.`ID GJ• `h '.:17 "
NAME-OF SPOUSE ' SPOUSE,SOCIAL SEC
f� OFFICE USE ONLY
DATE RECEIVED ! i e5 CASH RECEIVED{$Y- y