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Please check one: New � Addition � . <br /> aos SrrE 2 0(� � � � <br /> ��� <br /> Owner's�Tame Telephone Number - <br /> Mailing Address J��o � <br /> � Sprinkler Contractor's Name � _ Telephone Number // a <br /> Contact Person , <br /> Mailing Address � � � • � .5�.5�3 y�f <br /> WATER SUPPLY � ' <br /> Lake Well City <br /> �ACKFLOW DEVICE ` ' " <br /> AVB PVB X <br /> Year of � <br /> Make Model anufacture �uanti <br /> Snrinklers <br /> - TOTAL � <br /> HYDRAIJLIC CALCITLATI(�N Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. �,, <br /> No. of Sprinklers: <br /> Total Water Required: GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ _ 35.00 <br /> 2. State Surcharge. $ _ .50 <br /> 3. �1ai1-In Fee $ 1.50 <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) $ <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees to <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> Applicant Date �.� • � <br /> ����x:x����������x��x�����������x�*�x�:�a�����x���xx����x�����x�x�:x����x���x�x����x�����x������� <br /> Approved ,,� Approved with Corrections Denied <br /> Reviewed b : <br /> Date D ��� <br />