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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 /> MI-IrrigationWeD <br /> DISTANCE TO TANHS(S) <br /> ft <br /> ft <br /> , <br /> ft. <br /> Moultoring Well ft. <br /> Other ft. <br /> 14. WiD the tank(s)pending closure be replaced with an aboveground or underground storage tauk(s)?YES[]NO[] <br /> 15. Indicate the responsible partyto be billed for additional PHS-EHD staff time expended beyond 3 boar 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 �T <br /> MalUg Address �-77 ,J O 21 f1 1Nl&t=T CIO--L <br /> � � 4S`( 6 <br /> Day Phone Number - <br /> . ( ojV t6t <br /> Si azure Title Date—r—�--- <br /> i <br /> I <br /> I <br /> EH 23 046(Revised 08/13/99) Page 6 <br />