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I.I. While it the depth to groundoater? _ Unknown <br /> I)eseribe the source ee in(ormellont <br /> 53. Are there sny water wNFs on this parcel or adjacent properties? YVS NO <br /> TYPE OP WELLS DISTANcz TO TAMS) <br /> Public Well R. <br /> Private Well R <br /> Irtigodon Well 1t. <br /> Monitoring Well R <br /> Other <br /> W, Will the tank(i) pending closure be replaced with an aboveground or gudoMmuad storage took(%)? YESM Ott <br /> !K. Indleste the responsible party to be billed for additional PH$-GND stet{time expended beyond ] hour minirb: <br /> permit payment per task. If the party designated below ie different than the permit applicant, e.g. property <br /> Owner, the pil,ty must acknowledge this responsibility for the billing by signature and dale below. <br /> iifalUug Address Q �u� i 7 srrr fzl— // <br /> lm <br /> Day`Phone Number (.__ �J 'Srll <br /> SlRnadtre Ttlle Date (/ <br /> Posait'Fax Note 7671 Daae - oT'""` <br /> ro <br /> ac <br /> 'Ar <br /> Phan*a heM <br /> Fax <br /> I'iH %? 014 (Rev isso 9/11/9,1) Page e <br />