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12. What is the depth to groundwater? 35 <br /> Describe the source of information: <br /> s� �c9rxq�-`�ln <br /> 13. Are there any water wells on this parcelor adjacent properties? YES j NO <br /> TYPE OF WELLS DISTANCE <br /> ETTOOTANHS(S) <br /> Public Well <br /> Private Well 1 <br /> Irrigation Well uN tt <br /> Monitoring Well 137LZ fL <br /> Other i< <br /> 14. win the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES()NO(j <br /> 15. indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br /> per tank. if the party designated below is different than the permit applicant,e.g.property owner,the party must acknowledge <br /> this responsibility for the billing bysignature and date below. <br /> Name tj(' i(-.f1a DCS 1-r�� 1 <br /> Malling Address 5 rI D t f�� 7 `� �QG � �V0 <br /> Day Phone Number oG( 1 ) l V <br /> Signature Title Date <br /> EH 23 046(Revised 08113/99) Page 6 <br />