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1?, What is the depth to groundwater? O <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES O NO J r <br /> TYPE OF WELLS I DLSTAINCE TO TANKS(S) <br /> Public Well <br /> .Za'DD ft <br /> i <br /> Private Well I ft. j <br /> Irrigation Weil I FL <br /> Monitoring Well <br /> I Sao { ft <br /> Other tt <br /> Id. Will the tank(s) pending closure be replaced with an above,r and or underground storage tank(s)? YES[ J NOV� <br /> 1:. Indicate the responsible parry to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br /> permit payment per tank. If the parry designated below is 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 /> I <br /> Name `SZ StYI !T ��YS i7 /�,, e� <br /> ,hailing Address �� Va��/ /771 S�b G(� e5?A- <br /> Day Phone Number (�� ) -r73 2- <br /> Signature Tit Dace <br /> 4 me�A <br /> EH 33 045 ;Revised 7110i95) pa_'- 6 <br />