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rvv l •„tin..r,1V 1CLL\'i1LL CGJ—JJJ—CJGO IV•CGJ 1 1T • rv�•V.a <br /> Oe-21-1' 02:SIPM FPOtl SEMCO TO 5992506 P.03 <br /> i <br /> , <br /> jl <br /> �I <br /> I� <br /> , <br /> 12. Wts it is the depth to oroxndwster7 ?-G' <br /> I `be th ource of informsn• <br /> ]3. Arithere any water welts an tkib' par!.f �e +dj+�.+.t properties? YES: [ J NO nt <br /> IIS L-- <br /> TYPE OF WYLLS GMSTANCE TO TANKS($) <br /> f Pablic Well It. <br /> Private Well. ft. <br /> Trrigntinn_Wall ft. <br /> Monitoring Weil R If <br /> I� <br /> 14. W I li the atmins} pending ehxure !x replaced with An abovegrinmd or aadetgio nad storage taWs)? YES[ [ NO[ ) <br /> 15. Ind�2 to rhe respomaibia prrty tr. he Di1lrJ n.. aJJiU•n.al tYt:-Cy staff time impcadod bcvoad 3 your minimum � <br /> per it payment per Mak. If the patty desigaAreA heti+w is difremilt than the permit 9pptic211t, e.g. property <br /> ow M. the party mmst 2cl aowtedea thin rr.rnaxihMty for the billing by signature And date below. <br /> Nagda�.K.� tali �QQ"" ,C` �� ,J ..,,,,,, <br /> ,M2'iing 'Acirpss l oy t1T. S__cT"4 r i'7• i�•-I . ..0 � <br /> On iPhone Number <br /> stg a Title Bate <br /> I, lI <br /> !i <br /> I <br /> EH 23 046 IRrvised 9171>%) p2ge b <br /> � I <br /> TOTAL F.03 <br /> 08-24-1998 07:30RM 209 599 2506 P.03 <br />