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ST LUCIE COUNTY WATER & SEWER DISTRICT (SLCU)
NEW CUSTOMER APPLICATION
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NAME �Q 'e' CXQ f-e I�Dyo e-s I n C-
ACCT. # / L) --s 5-
SERVICE ADDRESS_ 17rv.3 . & ILA 41
SUBDIVISION AI Lh r
LOT
39
BLOCK
< < � � • l� • _ ILA � � � �l .L' � � • �
PHONE # 1-7Q-9379 'Ln70-7 MOVE IN/CLOSING 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 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.
APPLICANT ''AGREES THAT APPLICANT WILL BEGIN PAYING BASE FACILITY CHARGES FOR THE UTIILTTY SERVICE
APPLIED FOR ON THE DAY THE WATER METER OR OTHER UTILITY SERVICE CONNECTION IS INSTALLED AT
APPLICANT'S PROPERTY, REGARDLESS OF WHEN APPLICANT STARTS UTILIZING THE METER AND/OR SERVICE.
CUSTOMER SIGNATURE
NAME OF SPOUSE
SOCIAL SEC/FED ID -7-7
SPOUSE SOCIAL
•� OFFICE USE ONLY �(
DATE RECEIVED �`� '�( CASH CHECK# J / �� RECEIVED BY