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SEVER RES
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SERVICE FEE
SAME DAY FEE
OVERTIME FEE'
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GUAR. REV.
LATERAL
TOTAL
SZ LUCK C.OLJIii Tl' iJTII,ITIEs _ P:O'. BOX 728FT.PIERCE FI. 34982
NAME
ACCT.
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SERVICE ADDRESS i i��`Er�C�
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SUBDIVISION
BILL INGADDRESS
PHONE # 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 ti 0 t£ _
NAME OF SPOUSE
SOCIAL SEC!
FED ID
SPOUSE SOCIAL SEC.
{` �OFFICE_USE� ONLY
DATE RECEIVED s # ' CASH CHIC # IRECEIVED BY -%�, l
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