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_.� . M ST LUCIE COUNTY UTILITIES P O BOX 728 FT PIERCE' FL 34982: .
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SEWER RES
NAME
METERSZ. M/F
I. IRR ACCT#
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SECURITY DEP SERVICE ADDRESS
'772/x.• t�, •
SERVICE FEE
SAM&DAY FEE
SUBDIVISION
OVERTIME FEE - LOTBLOCR'.
B
'ING ADD
S.
j �3� ., METER INSTALL` RE S'•5 1.O (�' l(_ � �P f�-
'!CFC/
FPUA CFC
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MOVE IN/CI;OSING'DATE
CFC/SEWER I
GUAR REV This application heresy request and authorizes the Utility to render water and/ I
services to the;premises described) or,sewage dts osa !
LATERAL'. rules and�regulahons,which byreference are.mad dance with the Utilities present or futyre.rates':
the Utility promptly fo
]} e a part of this"contract Applicant agrees to pay:
TOTAL CUSTOMERSDEPOSITS ah services in accordance with the established rules;and;regulations;
ARE NON NEGOTIABLE OR TRANSFERAB
"CUSTOMER .. , SOC ``L 4 LE
SIGI�?rTUIE-
$EDgD 5
NAMROF SPOU E
SPOUSE SOCIAI,`SEC ....
ONL
FFI
' ! �Y
CASH
DATE RECEIVED # e
—r--� _ RECEI
VED BY ✓ ,,,I