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,��,�c�� <br /> . �� <br /> Please check one: New � Addition <br /> JOB SITE �(6`� S��a�..��� 1��.�� <br /> Owner's Name (�A v� �, l-�(,��S Telephone Number <br /> Mailing Address S A w�C <br /> Sprinkler Contractor's Name /-J�G Telephone Number ���' `��'S� <br /> Contact Person ��,�� <br /> Mailing Address I�o �ox �'7 32 j �L--`Ji�o�f� S S��7 - �3Z � <br /> WATER SUPPLY ' � <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB�� RPZ <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers <br /> ,� -�6 `�� <br /> ��tia��o �`l-, c!� � <br /> TOTAL <br /> HYDRALTLIC CALCULATIONS 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 Surchar�e. $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ �'4� <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees <br /> to do all work ' trict accordance with the ordinances of the City and State regulations, and <br /> certifies that a st tements made on this application are complete, true and correct. <br /> ' � <br /> Applicant 1r Date �f 3 <br /> *�**�******��*******��x�*******x�***��***************�**�x�**************�**� <br /> Approved v Approved with Corrections Denied <br /> Reviewe b : l <br /> Date /�_'f� <br />