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`n G <br />12. What is the depth to groundwater? <br />Describe the source of information: , p��T'— SPRt p4c, 111C <br />13. Are there any water wells on this parcel or adjacent properties? YES <br />14. <br />15. <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <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 />Will the tank(s) pending closure be replaced with an abovegroundun erground torage tank(s)? YES[/,.",Of J <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►\ <br />Mailing Address Po �X SE`S �` �oN�' 1 cft "► <br />Day Phone Number <br />ature[ ti ..- <br />Signature <br />LP 53 <br />Title <br />Date <br />EH 23 046 (Revised /10/96) Page 6 <br />,f 29 <br />D to <br />