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12. What is the.depth to groundwater? <br /> Describe the source of information: <br /> C.4 .4e W W/C-C <br /> j 13. Are there any water wells on this parcel or adjacent properties? YES ( ] NO Qs, <br /> t TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well <br /> Private Well <br /> Irrigation Well R- <br /> k <br /> Monitoring Well It, <br /> Other rt ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)7 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 applicant, e.g. property <br /> owner, the party must acknowledge this,responsibillty. for the billing by signature and date below. <br /> i <br /> Name C�CL IL I -er ot. / C�e <br /> Mailing Address <br /> JI <br /> Day Phone Number ( Z2 9 ) 4 J - 2-44 7 <br /> Signature Title - Date -'�--- <br /> EH 23 046 (Revised 9111196) Paee 6 <br />