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12. Whar;d therCepth to ground**ted <br />Describe the soured of InftWMii j <br />13. Are there any water wells on this parcel or adpeetif pt b,*Hles? YM [ I NO [ I <br />OF WELIL9 <br />1319TANC9 TO `�AN"(ff) <br />Wefl <br />ft. <br />e Wen <br />rOther <br />ft. <br />ion Welloring <br />Well <br />It <br />M Will the tank(s) pending closure be replaced with sit eboregromW or underg. "d storage tank(s)? YES[ I NO[ I <br />is. Indicate the responsible peril to be billed ft addlilonal PHS-EHD staff time expended beyond 3 hour minimum <br />permit payment per tank. If the patty designated b0aw Is dlflerent than the permit applletut* e.g. property o+wnert <br />the party must sckttewledge MU reaponslbiilty far the billing by signature and date below. <br />Name <br />Mailing Address L�� ti �i Y�,�, .___.. S Co. 0, ��,.:r•lt <br />137 J <br />Day Phone Number <br />Page 6 <br />j % q� <br />Date <br />