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COMM ST.LUCIE COUNTY UTILITIES-P.O.BOX 728,FT.PIERCE,FL 34982
NAME .�'.-'
M/F
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IRR
CURITY DEP S
SS
SERVICE t"
NICE FEE EL- 61'e?
WE DAY FEE
LOT BLOCK
SUBDM—SION
"VERTIME FEE
SS. a
BILLING ADDRE
IETER INSTALL.
D TA L
TC-/WAT-ER`-----
TUA CFC PHONE.# MOVE IN/CLOSING DATE
7C/SEWER
......... disposal
...... This application
SUAR.REV. hereby request and authorizes the to render water andfoi sewage
'bed above in accordance with the Utilities -future rates,
present or.
services to the premises described
1 —LATERAL rules and regulations,which by reference are made apart of this*contiact.Applicant agrees Wpay.
the Utility promptly for such services
services in accordance with the established rules and regulations.
TOTAL CUSTOMERS DEPOSITS AR
-NON NEGOTIABLE OR TRANSFERABLE.
A SOCIAL SEC/ - -
2.22 i? I
.':1VAME OF SPOUSE SPOUSE SOCIAL SEC.
OFFICE USE ONLY "if,
DATE RECEIVED if CASH
9 M- 4 RECEIVED BY