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Please check one: New Addition <br /> JOB SITE W I /1ORTy6TWj51II7? 9,6 <br /> Owner's Name 6 . L, A1=)E-'M1 AJ Telephone Number 990 <br /> Mailing Address s grrl <br /> Sprinkler Contractor's Name Telephone Number <br /> Contact Person M p PJ <br /> Mailing Address /a 3 R5 /TLE7VyE`7DndKr3 &VA <br /> WATER SUPPLY ' SS�� <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB _ RPZ <br /> Year of <br /> Make Model Manufacture Quant1jy <br /> Sprinklers <br /> TOTAL <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 /> 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) $ 31-- JD <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 <br /> Approved Approved with Corrections Denied <br /> Reviewed by: � <br /> rj�v� Date <br /> 'lam <br />