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%.. <br /> 12. What is the depth to groundwater? <br /> Describe the source of Information: <br /> II, <br /> 13. Are there any water wells on this parcel or adjacent properties? YIM [] NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well tL <br /> Private Well It. <br /> Irrigation Well rL <br /> Monitoring Well It. 1 <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES[]NO(] <br /> 15. Indicate the responsible party to be billed for additional PHS•EHD staff time expended beyond 3 hour minimum permit payment <br /> per tank. If the party designated below is different than the permit applicant,e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name <br /> Mailing Address1771�Q [✓ _ ProitA- -h- <br /> Day Phone Number <br /> `8- - yie.�ni�4 // 9e <br /> Blgti� — ro1�1 e — Datb <br /> EH 23 046(Revised 10/19/98) Page 6 <br />