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i2fii flf �1 11939 2094683433 FIFTH FLUOR FAtat bb <br /> M Wbat Is the depth to graandwatarl —15 [rc,-2S- (Ir- <br /> Describe <br /> r_Describe the source of information: - — - <br /> 6�zG��.a laa,lt�uva� We-bstt� <br /> 13. Are[here any water wells as this parcel or adjacent properties? M [] NO I� <br /> TYPE Or WMM MANCE TO TAxSsM <br /> Public Well fL <br /> PriPBre WCU it <br /> Irrigation Well tc <br /> Monitoring Well it <br /> Other ft <br /> 14. Will the tanks)pending closure be replaced with an abovag and or undergrmmd storage tank(s)?Mq)NO[] <br /> 15. ludlcato the responsible part/to be billed for additional P99-MM staff lima expended beyond 3 boar minimum permit payment <br /> per iasis. tf the party designated balow is di fereat dum the permit applicant,a.g.prOPOM owner,the par$must acknowledge <br /> this responsibility for the killing by signature and data below. <br /> r �� S+- 1 <br /> Name <br /> iKaftg Address y o oS Fn r T w a e-o rL �y 52 D <br /> Day Phone Number(_ _� 17h 21 L-1 <br /> T, ,- TSk <br /> Signamre Title Date <br /> r <br /> i <br /> Ell 23 046(Reyrsed 08/13149) Page 6 <br /> 12/10/02 TILE 09;43 [TX/RX NO 87091 005 <br />