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i • <br /> What is the depth to groundwater? A 1010=x CdA4 / Z o <br /> Describe the source of information: <br /> O W L <br /> G LSn oT ='97-G Derr' <br /> _. Are there any water wells on this parcel or adjacent properties? YES NO ( J <br /> TYPE OF WELLS I DISI'+INCE TO MUNKS(S) <br /> Public Well I ft. <br /> Private Weil I ft. <br /> i <br /> Irrigation Well ` ft. j <br /> G/oStSt .Monitoring Well ! /S'C? ft. <br /> fother I ft. <br /> WiII the tanks) pending closure be replaced with a �ovegmund r unde.-;round storage tankis)? YESj?Q YO( J <br /> _ Indicate the responsible party to be billed for additional PHS-£HD staff time expended beyond a` hour minimum <br /> permit payment per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the parry must acknowledge this responsibility for the billing by signature and date below. <br /> Name Lit. u//' PL/7 G � / ��.7/��/J <br /> 'Miffing Address /� 67, BOX GfI• - <br /> Day Phone Number ( a0 9 ) 992-— 'TO <br /> s7-11lion Sg/'Y/Ge,5 <br /> Signature Title ai' Date -r <br /> • <br /> _.. a 046 (Revised 9/11196) Page 6 <br />