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z <br /> 12 What is the depth to groundwater? �' � ' � + IN C�O FI-M)0 GAAL` <br /> Describe the source of information: l TD w coN5� mlz 1 s <br /> 13. Are there any water wells on this parcel or adjacent properties? YES g NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well �4p ft. . <br /> W C-"— <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 <br /> tank(s)?YES[] NOX <br /> 15_ Indicate the responsible party to be billed for additional 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 % zhm� �r�9 6 S i Ci ��S �� C&-T&- '' <br /> q <br /> Mailing Address icy 3 C� r V�I E 1-fir ` �% C� � r�`� <br /> Day Phone Number( ) I Z 2J _ <br /> Srg=ture Title Date <br /> EH 23 046(Revised l0/16/03) Page 6 <br />