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. . ����J� <br /> Please check one: New Addition c�� <br /> JOB STTE <br /> Owner's Name ��Y°��/��'� (v�V��q ti� Telephone Number L1� �" g�� I <br /> M�g aaa�ess 1 �;��� C�o 1���i S �� ��n�� � o� � � <br /> Sprinkler Contractor's Name ' Q�� ~-�n � Telephone Number �L)�����3 � <br /> Contact Person ��,� �� o� r��,1�' <br /> Mailing Address� 6� L � C ' �`^�W`e S� ����w� � • <br /> `VATER SUPPLY <br /> Lake�� Well City <br /> i, BACKFLOW DEVICE <br /> ! . AVB N�F PVB ti' /a- <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers _ i�1�-���- �Q�}� � �1 � � .rl�p�. �'° �`�v <br /> -� <br /> � 3 s_ TOTAL <br /> � _�rt � . �� <br /> HYDR�t`7LIC CALCITLATIONS Design Data: <br /> �'���2 Area of Application: f������ 11� � Sq. Ft. <br /> Coverage per Sprinkler: `3s � r��''�} Sq. Ft. <br /> No. of Sprinklers: � � � � � �-'2 `���•� <br /> Total Water Required: �.3�� g - +��`'� . GPM <br /> PERIVIIT FEE CALCULATION <br /> 1. Pernut Fee $ 35.00 <br /> 2. State Surchazee $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ <br /> ;3 7. �c <br /> The undersi;ned hereby applies to the City for issuance of a Sprinkler System Permit, 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 conect. <br /> � <br /> A lica � V- � � � <br /> PP Dat �k I � � � � / <br /> ************************ * ***************************************************** <br /> Approved proved with Corrections Denied <br /> Reviewed by: � � <br /> �/� ���C� Date_ ( �-�-��� �� <br />