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/SEWER
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COMM
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M/F
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SECURITY DEP
SERVICE FEE
SAME DAY FEE
' �1, OVERTIME FEE
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CFC/WATER
FPUA CFC
CFC/SEWER
GUAR. REV.
LATERAL
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ST. LUCIE COUNTY UTILITIES - P.O. BOX 728, FT. PIERCE, FL 34982
NAME Tnr+
RECEIVED
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^` AUG 10 2021
ACCT. # I V
SERVICE ADDRESS
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AV
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SUBDIVISION .-Y)Uiax f Ney es+azes
LOT BLOCK
BILLING ADDRESS a0 I S W �OQfA a- k IAC\-P- U\\d VSL C_� 3q qq
EMAIL ADDRESS: ?5l� (-O h' k_r
PHONE y� Ip 1 1� 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 Utility promptly for such services in accordance with the established
rules and regulations. CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR
TRANSFERABLE.
CUSTOMER _
SIGNATURE J L( N Cc
SOCIAL SEC/FED ID
NAME OF SPOUSE
SPOUSE SOCIAL
OFFICE USE ONLY
DATE RECEIVED 4_/5_)-/ CASH 64 M V- �(3 �/ RECEIVED BY vt✓)a-A Lam'
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