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30 <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> & U/ ^7XI'(ee t) 4' <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 ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage <br /> tank(s)?YES[] NOK <br /> 15. Indicate the responsible party to be billed for additional 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 responsibility for the billing by signature and date below. <br /> Name D/'/( �fry"!'-/Toat <br /> el <br /> Mailing Address :z <br /> Day Phone Number <br /> ��-`���a�e�.i�G�2-S��'�LJ l'►'d' lFC �� y9/a7/ay <br /> Signature Tie Date <br /> EH 23 046(Revised l0/16/03) Page 6 <br />