Laserfiche WebLink
1 <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES ( J NO ( J <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES( NO[ J <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br /> permit payment per tank. If the party 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 /> Name /I // l� �UJPOIIAV <br /> Mailing Address _ o! ER 59A) <br /> Day Phone Number a �7 7 3 41 <br /> 12— l <br /> Signature Title Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />