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� y��. <br /> ' ` �.� j�� <br /> Please check one: New � Addition � <br /> aoB srrE � 7 �7�J ��'/�s�°o �c�,>Y�- �v <br /> Owner's Name � :�/ /�(�/�� Telephone Number� ��-���-� <br /> Q ��G/� �'�.�C_' �"G'> >Yf-- ��j J.�/j��11� �/qit/� l�1�V c�J`-3�l'02 <br /> Mailinb Address d <br /> Sprinkler Contractor's Name �/YG�i�t�/L��r/�1C L,q�v�,?�iS Telephone Number �7�-�-�'�� <br /> , . <br /> Contact Person �(��L� ��'�l�l �� <br /> Mailing Address J� ���( �/���/1l��- �� �0���1.� /�.:%Y/�/ �`����f <br /> WATER P Y <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> ., Make Model Manufacture Quantity <br /> i ler ,yti��;� �/� / G % <br /> �,��► .' � � /�j / <br /> �,iY � ` i T� / �l � <br /> TOTAI, � �, � <br /> HYDRAULIC 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 /> �ERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .50 <br /> 3. Mail-In Fee $ ,,�g,- <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 ict ccordance with the ordinances of the City and State regulations, and certifies <br /> that ail state ents ade on ' �application complete, true and correct. <br /> i <br /> / <br /> Applicant � Date G ^�� �� <br /> �k�k�k�k��k��K���k� �k�'�e�c.��k��k�k�k�k�*�k��k����k��k�?e��(ex�e�k�k�e�c*��!c�k����k�k*a���*��k�kx�kx�k3c�e�k�x*�k�k�k� <br /> �' <br /> Approved Approved with Corrections Denied <br /> Reviewed b . - �� � <br /> Date �'�y�� <br />