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14. <br />15. <br />• <br />What is the depth to groundwater? `Wlen 1'4' 4 <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />I DISTANCE TO TANKS(S7 <br />Public Well <br />ft. <br />Private Well <br />//© ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />0 <br />YES LX NO [ j <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YESP( NO[ [ <br />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 party must acknowledge this responsibility for the billing by signature and date below. <br />Name •+t�.crr b }'rc )0 w (-c .s. `7 > ►y L <br />Mailing Address r to ox 7 X-C— <br />Day Phone Number ( '7 07 ) q & �— - k� <br />Signature Title Date <br />EH 23 046 (Revised 9/11/96) Page 6 <br />