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0 0 <br /> 12. What is the depthgroundwater? <br /> to <br /> Describe the <br /> source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties. <br /> YES J NO� <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well <br /> ft. <br /> Private Well <br /> ft. <br /> Irrigation Well <br /> ft. <br /> Monitoring Well <br /> Ct. <br /> Other <br /> ft. <br /> IJ. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES, 1 NOK <br /> i-. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br /> permit payment per tank. It the party designated below is different than the permit applicant, e.g. property <br /> owner,(the party mus[ acknowledge this responsibility for the billing by signature and date below. <br /> Name Uoi lC t� (-Ijj <br /> ,Nailing Address Z(c �, �( Z PC <br /> S T . <br /> Div Phone Number <br /> Signature `'F c� A=- }� <br /> Ti le l ( � �l <br /> Date <br /> EH 23 046 (Revised 9/11196) <br /> Pigc 6 <br />