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. . � <br /> Please check one: New �✓ Addition <br /> JOB STTE <br /> Owner's Name _ _S;��J o�v �r .'`k�� tJ Telephone Number <br /> Mailing Address .� ,� .��� q.s C o �I � � <br /> Sprinkler Contractor's Name (���c. �/�i�1 ����.y TelephoneNumber <br /> Contact Person �!�'U�.�, o �..� <br /> � <br /> Mailing Address %O_S � � N� A�J� � ' <br /> �VATER SUPPLY � <br /> Lake Well City � <br /> BACKFLO`V DEVICE / - <br /> AVB P VB `/ <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers /,�/� �� � � �'� �� /�� �� /� <br /> /�,lra rc� �'� %�� � �C a° � .�� <br /> /1/�.,,rJ 7'�.✓" /� '' �D(/ oC �o� � <br /> TOTAL � s"l <br /> HYDRAULIC CALCITLATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Covera�e per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PERitiIIT FEE CALCULATION <br /> 1. Pernut Fee $ 3 5.00 <br /> 2. State Surcharse $ .50 <br /> 3. Maii-In Fee $ 1.50 <br /> 4. TOTAL PERII�IIT FEE (Add lines 1-3 above) $ <br /> The undersi�ned hereby applies to the City for issuance of a Sprinkler System Permit, a�rees to do <br /> all�vork 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 /> � <br /> Applicant ` Date_ %` ,,2 � - c�(� <br /> ******�*****�************�*** *********�***************************************** <br /> Approved ,��� Approved with Corrections Denied <br /> Reviewed by: � �� <br /> Date 7� 2� " D(� <br />