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ATER
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ST LUCIE COUNTY WATER &.SEWER DISTRICT (SLCU)
NEW CUSTOMER APPLICATION
NAME j1AP_ 1ka!�A
ACCT. #
SERVICE
`7`
Fort Pierce, FL 34945
SUBDNISION6ea- ad�
C , LOT BLOCK
BILLING
VC_ /JC Tj1,q ,&a,41
EMAILADDRESS:. DMPARRINO aODRHORTON.COM
PHONE c�2 ) �c ✓�' / 7. /
MOVE IN/CLOSING DATE
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This application hereby requests and authorizes the Utilityto render water and/or sewage disposal
services to the premises described above in accordance witth the Utilities present or future rates, rules and
regulations, which by reference are made a part of this contract. Applicant agrees to pay Utility promptly for
such services in accordance with the established rules and regulations.
CUSTOMERS DEPOSI7T ARE NON NEGOTIABLE OR TRANSFERABLE.
APPLICANT AGREES THAT APPLICANT WILL BEGIN PAYING BASE FACIIM CHARGES FOR THE UTILITY SERVICE
a'APPLICANTS
APPLIED FOR ON THE DAY THE WATER METER OR OTHER UTH.,iTY SERVICE CONNECTION IS INSTALLED AT
PROPERTY, REGARDLESS OF WHEN APPLICANT STARTS UTILXZJ TG THE METER AND/OR SERVICE.
CUSTOMER SIGNATURE Z2A;f� Waite SOCIALSEC/FED ID IX—
NAME OF SPOUSE SPOUSE SOCIAL -
OFFICE USE ONLY ,/►`� � f�L�4i�C/\
DATE -RECEIVED � CASH CW6@ E# /('L RECEIVED BY i