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lH <br />What is the depth to groundwater? 10 <br />< 7 ! t <br />Describe the source of information: vdv ' o Wt 'G S- <br />13. Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WEUS <br />DISTANCE TOT (S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. S <br />Other <br />ft. <br />i <br />YES [] NO [] <br />14. Will the tank(s) pending closure be replaced with an aboveground and nd orage tank(s)? YES NO [ j <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name <br />Mailing Address <br />Day Phone Number( / ) �2 <br />0 <br />Signature <br />Page 6 <br />Date <br />