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. a��� ► <br /> , C��� �— <br /> Please check one: New � Addition <br /> JOB SITE �� Z � ��i`�C/� � ��,�� '�.,Q��I (� �— <br /> Owner's Name �� lN` �'V(,j3� G�' Telephone Number �7 Z- � �7� <br /> Mailing Address �� �Z-� �f-1�j L�E� �,� <br /> .r--� '�-�5��,.1 `t.�� �?�_� ����c...� <br /> Sprinkler Contractor's Name ��� �� L ( L'�� Te eph�ne umber <br /> Contact Person ��I r� �.�����l�-- <br /> Mailing Address -`-r� �'�� �Y1. ��(`'�-'L� (-�` . n,t�t-'�e �,i��' �-���� <br /> � �, <br /> `VATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> � Year of <br /> Make Model Manufacture uantit <br /> S rinklers + � <br /> ; - ,,� � <br /> ��70 <br /> TOTAL � <br /> HYDRAUI,IC CALCULATIONS Design Data: <br /> ,—� -� �'j�j�> <br /> Area of Application: �� Sq. Ft. <br /> Coverage per Sprinkler: - �� - �s'�' Sq. Ft. <br /> .� ,. <br /> No. of Sprinklers: <br /> Total Water Required: .� GPM � <br /> �:.�_ f <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ " <br /> � V� �� � � <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System ermit, agrees to <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> Applicant Date ` ��Lc✓�� <br /> ���**x�**��*�** *� ***� *�*=�*****�*****�x��*********�****�*�**�x**�******** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: `� <br /> � <br /> Date <br />