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12. what is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? ` C tl ES ( ] NO [ ] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public well rC10 t ft <br /> Private well } * ft <br /> Irrigation well 1` ft <br /> Monitoring Well AW t ft <br /> Other it <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO( ] <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 party designated below is different than the permit appi9cant, e.g, property owner, <br /> the party must admowledge this responsibility for the billing by signature and date below. <br /> ! ' <br /> Name (.( <br /> Mailing Address '. toe <br /> Day Phone Number ( a�fr , Yr!O p 33�S Ii <br /> Signature <br /> Page 6 <br />