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i <br /> It. Mal Is the depth to groundwnler? 7t7 Xr <br /> Describe the source of Inforbenilom S . <br /> i <br /> I ' <br /> IJ. Are there any Filer wells on this parcel or adjacent properties? <br /> YES ( 1 NO 'l <br /> I jpF,OF WE1,19 IIIRI'ANCF,Tll 't'ANRS(S) <br /> Public Well n' <br /> private Well R. <br /> trrlgnblon Well <br /> fl. <br /> i <br /> hinnlloring Well <br /> I <br /> Omer n <br /> l4. WIII the Inuk(s) pending closure Ire replaced with an ■b"vegroonJ or underground sloroge lonk(s)? YES( I NO( I <br /> lS. Indlcnle the responsible pnrly to be billed for additional PIIS-EIID stnff time expended beyond J hour minimum i <br /> permit pnymenl per took. If the party designated below Is different than the permlt applleao4 e.g. properly ownerb <br /> Ilse pnrly must ecknowiedge this responsibility for the bllllog by signnlure and dole below. i <br /> Nome . O <br /> S7 <br /> Mnlling Address O <br /> �7 I� <br /> I)ny phone Number (�1 7 L� / / 9 <br /> Dnle <br /> Int <br /> i, <br /> i <br /> ' I <br /> Page 6 <br />