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M <br />M <br />What is the depth to gro r? <br />Describe the source of Information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TOT S) <br />Public Well <br />ft. <br />Private Well <br />It. <br />Irrigation Well <br />ft. <br />Monitoring Wen <br />It. <br />Other <br />ft. <br />14 the tank(s) pending closure be replaced with an aboveground or underground storage s)? j NOld <br />15. Indicate the responsible party to be billed for additional PHS -EBD staff time expended beyond 3 hour minimum permit payment <br />per tank. If 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 />Namey-,r\ &1y '('G.6jN +_ - <br />Mailing Address �.®. �x 1 LI 03 <br />Day Phone Number <br />._. A <br />a-). - q� <br />EH 23 046 (Revised 10/19/98) Page 6 <br />