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��-1u-177 ria•x�rri rKuri TU 14252518782 P.05 <br /> i 2 What i the da'thto aummvZteX7 <br /> descriie the s u(if Wfa madom <br /> 3. thla any water weus an tis <br /> Pared or a jac=Popertles? <br /> ms E 1 Ka E� <br /> TYPE OF WELLYDLS1'AHCS'i`t)TANKS(s) <br /> Pub1Tc Weil <br /> Pttvate Weil tL <br /> lrrimQa Weil rL <br /> Maatioring Well fL <br /> Q I R <br /> Will the t"s)pendfng dosum be rno ed with an mbovegruaad or=daem=d storm, tani�s)? 1 <br /> ladtca the re�ffibte party to be billed for addlifanai stf tf m emended bey 3 bear m p payment <br /> per If the pu%y desipased below Is'Me=than cbe pe=ft a.ppiicaat,e.g-property owacr,the gaM mnst act=omfedge <br /> tris resa�hility fur tba hOug by d=atum and date beiaw. <br /> Name /LL /►'��I?� �2�.p /LOG7J� <br /> 3 41A ddress <br /> Day lh a <br /> I <br /> l <br /> 23 046 (Revised 10/19/93) Page 6 <br /> i <br /> I <br /> i <br />