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5-27-04; 8:43AM; ;925 551 7888 # 28/ 34 <br /> 03/05/2004 13:59 209468343 FIFTH FLOOR PAGE 10 <br /> 12. Wbat is the depth to gronudwater?� f�IC�te�W ' <br /> a <br /> Desedbe the source of iaforMaIUM <br /> 13. Are there any water wells an this parcel or adjacent preiiertles? YRS No <br /> rM Q8'i am DISTANCH fits <br /> Publte Well Tt. <br /> Ylfvate We11 ft. <br /> trrfgation,Well tc . <br /> MenlWdug Well ft. <br /> tither n <br /> 14. WM the taulo)pendlagslosure be replaced udt6 in aboveground or7ndstMund storage tankp)?V-WNa(j <br /> �` I <br /> 15. indicate tha Eesponsible party to be bllled for additional PHS stat(time expended beyond 3 hour permit payment <br /> .Ver tank. Utho pang designated belowis differeut fta the Pe=ft eDpileaut,&.&prol)cM owner,the parlpmust acknowledge <br /> this respoaslblilty for the billing by signature and date below. <br /> Name '� <br /> MaMng Address C L's d <br /> Day Phone Number[ <br /> 1,6 <br /> Signa e Title nate <br /> BH 23 046(Reviscd 08/13199) Page 6 <br />