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11-1 TO 9579628 P.03 <br /> 05-05-1995 03:3ZPM FROM SEMCO • <br /> 22. What Ls tI}er�eptyh to gronadwata�! . <br /> be tthf�e source of lahsrmadon: /�� <br /> 17. Are there any nater walls on this parol ar adaaot PrWert"er YES i I NO <br /> TYPE OF WIIZ3 3)BTANCE TO TANXSM <br /> N tic Wclh <br /> Prlrate Well R <br /> Irrigation Well fL <br /> Monitorfng Well fc <br /> Other I ft. <br /> xl. Wi!I the tank(s) pending elesare 1te r^_placed with as abowegaaad or moderpra d storage tanks)? YES( ] <br /> Lc, Indicate the responsible parry to be billed for additional PEs-EAT? staff time =pendad bayond 3 hour mhnlmum <br /> permit payment per t.;;nL if the party designated below is dUrcreat than the permit applicant, e_g. properry Qtvner, <br /> the parry mast eclaiowWjt this responsibility for the Wing by signatafe and daft below. <br /> Nave o ngfE z - vo <br /> NlanSngAddress lab ! ®1 �1 {(Trt( <br /> Day Phone Number y 7 S <br /> nate <br /> gisnatrue <br /> Page 6 <br /> TOTAL P.03 <br /> 06-01-1995 10:02HP1 209 957 9628 P.03 <br />