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WATER COMM ST LUCIE COUNTY UTILITIES-P.O.BOX 7211,FT.PIERCE,FL 34982
SEWER RES NAME lr
METER SZ. MIF .�
t IRR ACCT.#
$ SECURITY DEP SERVICE ADDRESS
SERVICE FEE
1 SAME DAY FEE
i SUBDIVISION �T�� LOT BLOCK
OVERTIME FEE S /
I E BILLINGADDRESS !7��1 P(ho� l�tt�l� .f�,�A
METER INSTALL.'
CFC/WATER
I FPUA CFC PHONE# c fX� -.(! ( I fj MOVE IN/CLOSING DATE
CFC/SEWER
This application hereby request and authorizes the Utility to render water and/or sewage disposal
GUAR REV
{ � services to the premises described above in accordance with the Utilities present or future rates,
LATERAL rules and regulations,which by reference are made a part of this contract.Applicant agrees to pay
I { + the Utility promptly for such services in accordance with the established rules and regulations.
TOTAL CUSTOMERS DEPOSITS ARE NONNEGOTIABLE OR TRANSFERABLE.
CUSTOMER SOCIAL SEC/ �
SIGNATUREi(rl 1 FED ID
l NAME OF SPOUSE SPOUSE SOCIAL SEC.
f
OFFICE USE ONLY
i DATE RECEIVED CASH CHIC# iJ RECEIVED BY ,�✓'��
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