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istalled By ❑ Driller _, `Pump Contractor ❑ Other <br /> Concrete Pedestal ❑+Dimensions: Width ft Length ft Thick in ❑ Christy Dox ❑ Stove Pipe <br /> =;submersible❑ Turbine ❑ Other HPump Set ` ft Standing Water Level `"ft <br /> FY THAT i HAVE PREPARED THIS APPLICATION! AND THAT THE lfI.JORK WILL DE DONE IN ACCORDANCE WITH SAN <br /> 'Y ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> %CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ENSATION LAWS. <br /> NCE NOTICE REQUIRED FOR INNS m PLEASE CALL (299) 953-7697.117, <br /> ' 75 <br /> DATE <br /> k•� <br /> \ <br /> � <br /> � WIN <br /> r . Y <br /> y f <br /> P <br /> Y <br /> DEPARTMENT USE ONLY <br /> �Cepted By Date _ Area Employee ID# <br />