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12 What is the depth to groundwater9 �� <br /> Describe the source of information 04r.vrv-i Plv,,7► <br /> 13 Are there an water wells on this parcel or adjacent ra erties'7 YES NO <br /> Y p J P p �] �] <br /> TYPE OF DISTANCE TO <br /> ' WELLS TANKS(S) <br /> Public Well ft <br /> ' Private Well ft <br /> Irrigation Well ft <br /> ' Monitorfn Well ft <br /> Other ft <br /> 14 Will the tank(s) pending closure be replaced with an aboveground or underground storage <br /> tank(s)9 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 .L <br /> Mailing Address <br /> �l�' 1U. µcan��r Shoo fon <br /> ' Day Phone Number ( -D 9 ) <br /> ilk I A- XA,I <br /> Signature Title Liate <br /> ' EH 23 046 Revised 3/15/02 Page 6 <br />