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%%W ` 4 <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> S torl= �✓il"agcsV L�L/kVLz f�Lli(Z <br /> Q- <br /> 13. Are there any water wells on this parcel or adjacent properties? a- YES V NO I <br /> I{�175 <br /> TYPE OF WELLS DISTANCE TO TANKS(S) � <br /> Public Well ft. I�pag Er 6eZ�3 ItSILO• <br /> Private Well 1000 75 ft. <br /> Irrigation Well n• <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced wi an abovegrouud r underground storage tank(s)? YEat,/i NOI I <br /> 15. Indicate the responsible party to be billed for additions HS-EHD staff time expended beyond 3 hour minimum <br /> Ninimum <br /> permit payment per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the partly must acknowledge this responsibility for the billing by signature and date below. <br /> -3"l)�n�n- <br /> Name 4• \, C--0V"-(lT(J-CX tC)(A tn� <br /> Mailing Address �,� -V'C-"'('"5C �] k a <br /> Day Phone Number <br /> fA(rt(e_)(f <br /> Signature Title Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />