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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? YES [] NO ] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well It <br /> Private Well ft- <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other it. <br /> P <br /> 14. W11I the tanks)pending closure be replaced with an aboveground or underground storage ta*s)?YES[]N0 <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 responsibllity for the billing by signature and date below. <br /> Name g►�SL- 0iE xL.,;--� hCc).�t', I rA[— - <br /> Ic-` c <br /> 4 Mailing Address - ` e' * �-- A J` <br /> P <br /> s <br /> Day Phone Number( :JC) 1 } �1 Cv- w i`) <br /> I _ <br /> A Z<✓C> <br /> Signature <br /> Title Date <br /> P <br /> i <br /> P <br /> I <br /> EH 23 046(Revised 08/13199) Page 6 <br />