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WATER 'COMM ST. LUCIE COUNTY UTILITIES - P.O. BOX 728, FT. PIERCE, FL 34982
SEWER RES NAME PC (y ce1" 1 1- ItY e
METER SZ. M/F
IRR
$ !
SECURITY DEP
SERVICE FEE
- --
SAME DAY FEE
OVERTIME FEE
METER INSTALL.
CFC/WATER
FPUA CFC
CFC/SEWER
�y
% c • (I
GUAR. REV.
LATERAL
�y
$ 1 2 Y / • �
TOTAL
ACCT. #
SERVICI
SUBDIVISION )¢1 li°✓q %�� lr S�✓1� LOT' _i' BLOCK f7
BILLINGADDRESS
)J41 /l�,eP LI'J 47.
PHONE # y4 % %�� % `?✓� MOVE IN/CLOSING DATE
This application hereby request and authorizes the Utility to render water and/or sewage disposal
services to the premises described above in accordance -with the Utilities present or future rates,
rules and regulations, which by reference are made a part of this contract. Applicant agrees to pay
the Utility promptly for such services in accordance with the established rules and regulations.
CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
.CUSTOMER '
SIGNATURE %dAle
��►�
. 'NAME OF SPOUSE
DATE RECEIVED
SEC/
G
SPOUSE SOCIAL SEC.:
a
OFFICE USE ONLY
CASH CHK #• J��� RECEIVED BY.