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Od. <br />�-g99793: 2 2 P M EI. I. I S H CECH I IT I <br />d-1a:i 1 FF2Ca1 `E NC <br />C 209 SW e702 <br />12. Whet Is the depth to grroeadweter✓f S37Y.lili <br />Describe the source of Information: <br />13. <br />14. <br />is, <br />X <br />Are then any water wells on this parcel or adjacent peopariks? <br />TM OR WELL$ <br />DMTAMZ TO TANKSM <br />Pubtle Well <br />— R <br />Private Weil <br />Killing Address <br />Irrigation Well <br />-- R <br />Monitoring Well <br />L / <br />r'� / i/OGI7 <br />Other <br />^'— R <br />I�Cwf-- <br />YZS VxOfl <br />Will the tanks) pendens elo"rt be rrptaced with an abagtv4md or uedwgroaad storage tank(s)7 YSSN( N01 i <br />Indicate the responsible party to be billed for additionsd PHS -ETM suR time "peadd beyond 3 hour miaimam <br />permit payment per teak. If the party defeated below is dlthrest than the permlt ■pplieabt. &g. property <br />owner, the party mast acknowledge thb responsibility for the billlag by sipyature and date below, <br />'name c�c G(i�irt�[�t <br />YAW 2 <br />1a(f4WAtW1 <br />Killing Address <br />�OQ <br />rciesyt�^C <br />6�I <br />eV <br />4, �/ <br />L / <br />r'� / i/OGI7 <br />Day Phone Number <br />s <br />�w <br />1L " `,.1I�'�� <br />Tit1a <br />EH 23 046 (Revised 9111/96) Page 6 <br />Date <br />