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' <br /> 12, What is the.depth to groundwater? /A /V ,A <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO <br /> TYPE OF WELLS DISTANCE TO TANKS(S) � <br /> Public Wel) <br /> t <br /> Private Well ft, <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other It. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YESI J NOS I <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time, expended beyond 3 hour minimum <br /> permit payment per lank. if the party designated below 13 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 —.� �.r� iJC a i -- f' f. <br /> Mailing Address _5 y <br /> Day Phone Number ? '- lC3 S 4� <br /> �. ..�_.... M <br /> �TAM-T AJ <br /> nature irini Date <br /> k <br /> t <br /> Ell 23 046 (Revised 9111/96) Page 6 <br /> 4 f <br />