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12. <br />13. <br />14. <br />15. <br />What Is the depth to groundwater? <br />Describe the source of information <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />IL <br />Private Well <br />ft <br />[rrigatlon Well <br />ft <br />Monitoring Well <br />IL <br />Other <br />tt <br />YES 00[] <br />Will the tauNs) pending closure be replaced with an aboveground or underground storage tank(s)? YES ] NO(,J/ <br />Indicate the responsible party to be billed for additional PHSSEHD 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 by signature and date below. <br />Name <br />Mailing Address <br />U/2l 6 AJ <br />Day Phone Number ( 207 ) `� 3 / — D 7 el 9 - <br />Signature Title Date <br />EH 23 046 (Revised 10/ 19/98) Page 6 <br />