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v ✓ <br /> teal setsLzs6ez WdTZ:TO 9661—£1—t0 <br /> 01-00-1998 09;0" FROM SEMO TO- t77617S P.03 <br /> 1 <br /> 12. WIN a b the www W grondwater? `W ( J <br /> saner or 00 _ c. _ 'I'eC�T / <br /> n 10/� �O r r:�l <br /> r a <br /> i <br /> 13. Are 1 cry any water waft Or chit partal or adjacent prwcttys? YE3 11 NO I } <br /> TYPE OP WZUS DISTAMM TO TAPOMM <br /> Public Well R <br /> Prtwate Wen to <br /> irrigan" wen ft <br /> MoodtallLg Wer Sear $ <br /> j Otber tt <br /> 1 I <br /> 14. WM the tank(*) pmeliug doge be replaced with as abOregrdrMl Or wWkrprand storaga tank(s)? YESI i NO( I <br /> U. fodie a the resp0aaiWe party to be billed far adddivnal fWj-& U sof[time,expended beyond 3 hour mluimum <br /> perm{it paywMt per taab if the parry de 1pawd below is ifftreht than the permit appiiatot, eg, property <br /> Own , the parry rust aekno*tedge this reapondbility for the hetnng by'signature and date,blow, <br /> f <br /> ttaale <br /> X74{� ��✓ <br /> Mailyte wddran 33$ t FJW-re k I�tM a +4 s z 31 w <br /> Day Rhone Namber i 2ey5 ) 9 Y L-04 L <br /> Ii <br /> spell rw xtae nary <br /> I <br /> i <br /> EH 23 048(Revised 7110/9b) 6 . <br /> I <br /> TOTAL P.03 <br /> TO 37jVd SQN00 IIV9 S,llIS SL19LL96OZ OZ:6T 866WETl10 <br />