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4 � <br /> 12. What Is the depth to groundwater? <br /> Desc!?,M i L e�ot`Intoymatlo � <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [ N0A <br /> TYPE OF WELLS DISTANCE TO TANES(S) <br /> Public WeH fL R <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 tauk(s)?YES 0011 <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour /minimum permit payment <br /> per tank. If the party designated below Is different than the permit applicant,e.g.property owner,the party must acknowledge <br /> this responsibility for thee billing by signature and date below. <br /> Name <br /> Mailing Address �J W 1•ltl�"" t�rtt`u� � i )� �1 "� �IS�� <br /> Day Phone Number( I G►`SI ��y <br /> Signature Title — Date <br /> EH 23 046 (Revised 08/13/99). Page 6 <br />