Laserfiche WebLink
..01 <br /> 12. What is the depth to groundwater? S T <br /> Describe the source ofinformation: 1 <br /> KoNiloylK� 1Mr ]TS ]0 Cot+d ��9' K4i)� y1011W weF / <br /> � <br /> 7 <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO [ ] <br /> TYPE OF WELLS I DISTANCE TO TANKS(S) <br /> Public Well 00 ft. <br /> Private Well Z Q ft <br /> Irrigation Well — ft <br /> Monitoring Well fL <br /> Other — ft <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NOK <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br /> permit payment per tank. If the parry designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Ad - A irI <br /> Mailing Address P. O. QOx S570 70 , 5 ) o cl 7 o yN l I 2 5 10 Z <br /> Day Phone Number O 9 3 O <br /> 6- <br /> Signature Title Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />