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COMM ST.LUCIE COUNTY UTILITIES-P.O.BOX 728 FT.PIERCE FL 34982
SEWER . RES 01�.
j NAME
METER SZ.
IRR
ACCT.#
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$ SECURITY DEP SERVICE ADDRESS �.Y i t
SERVICE FEE
SAME DAY FEE
SUBDIVISION LOT BLOCK
OVERTIME FEE
. LJ METER INSTALL.• BILLING ADDRESS
CFC/WATER �` t -e jr L C' � C
FPUA CFC PHONE# - _ (� MOVE IN/CLOSING DATE
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CFC/SEWER
This application hereby request and authorizes the Utility to render water and/or sewage disposal
GUAR.REV. services to the premises described above in accordance with the Utilities present-or future rates,
LATERAL 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.
TOTAL CUSTOMERS DEPOSIT&ARE NON NEGOTIABLE OR TRANSFERABLE.
CUSTOMER ti SOCIAL SEC/ (�
SIGNATURE ��i� / FED ID
t ``
NAME OF SPOUSE i t t•-^'•3 SPOUSE SOCIAL SEC.
P
�O,1�FICE USE ONLY � ,
DATE RECEIVED c� % CASH' ' CHK# RECEIVED BY�