Laserfiche WebLink
0 <br /> 12. What is the depth to groundwater? /Q®, - /y /S"— 2 O eel:' ".A:aa'J S kA r UA5 <br /> Describe the source of information: ��- <br /> "' /k <br /> .4LSc� <br /> 1906197&-/ <br /> 13. Are there any water wells on this parcel or adjacent properties? YES M NO <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> GIoS�St Monitoring Well /S-p ft. R®u•S ®�e7'OQtN� <br /> Other ft. WCEL4 •5 't"®G/4Tt0 on/ ,S17-c-5„ <br /> 14. Will the tank(s) pending closure be replaced with a veground r underground storage tank(s)? YESP4 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 parry must acknowledge this responsibility for the billing by signature and date below. <br /> Name L.�.u//' E'./1 c /, • /c�.�./ Gti/> <br /> Mailing Address 9 000/ .ft �/O/J ,� Gf�• 9.529E <br /> Day Phone Number ( eZ0 2 ) 9i'2- 3.0¢® <br /> Signature Title Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />