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� A ����� �' <br /> Please check one: New Addition � <br /> JOB SI'TE �3/3S �/o�e'�`t/Ss,��" l/.� �ito�.,o �t�--. <br /> Owner's Name /�,r�„E �,��� Telephone Number <br /> Mailing Address 3 13 S �o.eT.�l�,� � �''ia.e.�o ��--- <br /> Sprinkler Contractor's Name SOUT/1 vi��� s,.,.� Telephone Number �I'SS-SSZ 3 F� <br /> Contact Person �„� ,�,�o,,,� � �� ��,,,�,,_ <br /> Mailing Address /�70 � Sb"`" S�x�T .a.�.� Z -:L bN, �,,,, 5s�?Z <br /> WATER SUPPL� ' <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB RPZ <br /> Year of <br /> Make Model Manufacture Ouantity <br /> Sprinklers f,�w�c_�'f° .e�om•� �i9` /S' <br /> - /f�a..�p /°LI�'I .�r� /?9G �3 <br /> TOTAL <br /> HYDRAULIC CALCIILATIONS 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 /> l. 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 undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> certifies that all statements made on this application are complete, true and correct. <br /> Applicant Date 9-aS- �'6 <br /> ***�*******�******�**********�*�****�*****�*��x�********�******�*********�***** <br /> Approved Approved with Corrections Denied <br /> Reviewed by• � <br /> Date /f�^�� <br /> ,� ,��ls <br /> l��e� ,� �l� /�J �1� ,�� !l�� b� <br /> a'��� � ���ll -� � , <br /> /I/ ���22 D�'� � �a� ,be ad� �'���' r �� � �m�� a�n��s11� <br /> ��' � � / <br />