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APR 3 0 2021
Lie Cty, ermltEing
NAME`/y
ST LUCIE COUNTY WATER & SEWER DISTRICT
NEW CUSTOMER APPLICATION
SERVICE ADDRESS
Fort Pierce, FL -34945
ram
SUBDIVISION LOT BLOCK
BILLING ADDRESS eve . � �r //Z 1
EMAILADDRREESS:/DfM�P2ARRIIN00-13RI-IORTON.COM
/
PHONE c/� rc.�Jf 9 / c7 MOVE IN/CLo$ING DATE
This application hereby requests 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 ofthis contract. Applicant agrees to pay Utility promptly for
such services in accordance with the.established rules and: regulations.: .
CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
APPLICANT AGREES WHAT APPLICANT WIILL.BEGIN PAYING. BASE FAC LM CHARGES FOR TEM VIM= SERVICE:.:
APPIM FOR ON THE DAY THE. WATER METER OR OTHER l]TILII.` - SERVICE CONNECZTON IS INSTALLED AT
APPLICAI'-WS PROPERTY, REGARDLESS OF WMN Al'PI,ICANT STARTS UTTI[MNGTHE METER AND/OR SERVICE.
CUSTOMER SIGNATURE ilu. Qit�� SOCIALSEC/FED iD
NAME OF SPOUSE SPOUSE SOCIAL-
NAME
USE ONLY
DATE -RECEIVED_ 3- ICI.2A CASH C Gl4#F- /J�L(� RECEIVED BY