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! <br /> . - <br /> Please check one: New � Addition <br /> aos srrE / 3�0 Se��-e '�4�� � <br /> Owner's Name ��„� W����-: TelephoneNumber L(7l 7/ 7� <br /> Mailing Address �c vw� <br /> Sprinkler Contractor's Name �rp�55��>r�u.Q_..�m��TelephoneNumber �C72-(�I�1 <br /> Contact Person rt,e-�' L.vec�< <br /> Mailing Address I S`(7S 1 g�' S�1. (i✓�i�t�-��o�n � � <br /> `VATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB P VB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers 1�;,�•+�,,r�- �-Z� ��" <br /> �762� s�c7 zc� <br /> � <br /> TOTAL �S ' <br /> HYDRAULIC CALCUI.ATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: �,� <br /> Total Water Required: Z� GpM <br /> PERNIIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> Z. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Pernut, agrees to do <br /> all work in strict accordance with the ordinances of the City and State regulations, and certifies that <br /> all statements made on this application are complete, true and correct. <br /> Applicant Date jca-�``T�� <br /> ***********************************************�****************�**************** <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: �� <br /> � Date /Q--�— �(9` <br />