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� � , � <br /> Please check one: New � Addition J <br /> JOB srrE � � � ��� fi� / � r�-,� v <br /> s � <br /> Owner's Name ���� � Telephone Number — <br /> � I, <br /> Mailing Address --�� �, ��S �L�,�� C � ���,�� V��c cJ (i'���:�n � <br /> Sprinkler Contractor's Name ,(;�{��,-�� � i;�v'rc�vti,e��� Telephone Number S'r(�`i7;� <br /> Contact Person ����' �� zr� ��� <br /> Mailing Address � /G� � e� �.�, �e_ /�i'9,l �v��t � S'"��/c/ ( <br /> WATER SUPPLY � <br /> Lake Well City �/_ <br /> BACKFLOW DEVICE <br /> AVB PVB � RPZ <br /> Year of <br /> Make Model Manufacture Quantitv <br /> Sprinklers ���r0 ���' � `�� -5 <br /> �" ���v �7�� -��> <br /> �ro�rai. � �; <br /> HYDRAUI.IC CALCULATIONS Design Data: <br /> Area of Application: ������� Sq. Ft. <br /> Coverage per Sprinkler: � v Sq. Ft. <br /> No. of Sprinklers: 5' <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) $ <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> certifies that all statements made on this application are complete, true and correct. <br /> � ' ��;�-7-�� '��/ <br /> Applicant � � Date <br /> ********x�********* **�**x�*�*****x�******�**�*x�****��*��*****x�*�***********��*** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: ' ----- � <br /> ��– � Date <br />