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12. <br />13. <br />14. <br />15. <br />What is the depth to groundwater? / O (4 C tJ <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANKS(: ) <br />Public Well <br />ft <br />Private Well <br />I ft. <br />Irrigation Well <br />rt <br />Monitoring Well <br />it. <br />Other <br />it. <br />YES [] NO[] <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES O[ ] <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br />per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />Name s%} 7- A, 4-M <br />Mailing AddressH71/A;z:_ <br />Day Phone Number ( <br />12, <br />Signature True Date <br />EH 23 046 (Revised 10/19/98) Page 6 <br />