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04�'17-'9S 1[): 21 %Y209 474 5600 S J Ii f: <br /> - Zou2 <br /> ' FROM ERMYS Z CO. � 4. 17. 1995 <br /> F. 1 <br /> 12° What 19 the depth Gd grouridwater - ' <br /> 1 I?eacrlbe the source of fororwituonr <br /> Jpt <br /> 13. Are them any water wells an thlq parcel or adjacent prnpertles? YES ( 1 N0 l 1 <br /> TUE OF WSLus DI5TANcE To 'I`ANgS(S) <br /> Public Well _ R <br /> rrirutt Well A R. <br /> iIrrigation Well t,J)A It. <br /> Monitoring Well IJ/4 lt. <br /> ' Otltet ll. <br /> 14. Will the tank(s) pending eiasure be replaced %vlth an abroretround or underground 51oruge tank(s)? YES[ Nt7( ] <br /> ' <br /> 15. Indicate the reaponsibic party to be. bilicd for addit(onvi PHS•E11D staIT time expended beyond 3 hour minimum <br /> jaetrrstft payment per tank, Ir(lie pnrty designated beluw Is dlrr mitt (flail the permit appllcant, E.g. property owner, <br /> the party raust acknowledge this rest:onsiblll(y ror (lac hIlllnU by signature mid dote below. <br /> ' Name M 1JG' r e it r <br /> Mailing address <br /> Daly P€rams Number 011 —, _ <br /> ' Signature Date <br /> 1 <br /> Pn�c G <br />