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a What is the dept¢to eroaadwatePt �. <br /> Describe the source or intornatlow <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NO'q <br /> c <br /> TYPt OF WELLS D49TAAOE TO TAHBS(S) <br /> Nub tlo Well it <br /> Pri7ats WeD 1. <br /> Irrigation Well ft. <br /> 191mt1torinpWell � <br /> Other h• <br /> 14. W.0 the tanks)pendia„closure be replaced with an abovaground or underground storage ta*s)?US[)Nyt� <br /> 75. Indicate the reS'porwbte party to be billed for additional PH$-ERD staff time expended beyond 3 hour minimoan_perntlt payment <br /> per.ant. if the party desi:nated below is dliferent than the parmlt a rt=t,e.g.property owner,the party must aelmowledV <br /> this rest=sibinty for the biiMe.b?signaturs and date bel - <br /> Name / e� F-eo/2L/ �Jro,c G� <br /> a fa!MS.addreae /,,-oS' c� `� 2.71 T-� �21�• <br /> Day Phone ffmnher j <br /> a � <br /> 9�siazsture Me Date <br /> EH 23 pa6'Rav;sed 38/131", Page 6 <br />