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, <br /> Please check one: New Addition <br /> JOB STTE <br /> Owner's Name Telephone Number <br /> Mailing Address <br /> Sprinkler Contractor's Name TelephoneNumber <br /> Contact Person <br /> Mailing Address � <br /> `VATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers <br /> � <br /> TOTAL <br /> HYDRAULIC CALCITLATIONS 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) $ <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 correct. <br /> Applicant Date <br /> ******************�***��********************************************************** <br /> Approved !.! � Approved with Corrections Denied <br /> Reviewed by: f ��� � <br /> � <br /> v Date_l j - � j - (�' <br />