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i <br /> 1� <br /> 12 What is the depth to groundwater? <br /> Describe the source of informatlon <br /> 13 Are there any water wells on this parcel or adjacent properties? YES [] NOV <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well it• <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 tank(s)?YES(k ' <br /> 1015 indicate the responsible party to be billed for additional PHS EHD staff time expended beyond 3 hour minimum permit payment <br /> per tank It 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 1 1 <br /> Mailing Address ` I <br /> Day Phone Number( 1 <br /> � 21 /2 0 <br /> Silatud Title Date <br /> I <br /> EH 23 046 (Revised 08113199) Page 6 <br />