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U What is the depth to groundwater? d <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? UNC , YES [] NO'6l] <br /> NO �N�L1_S Ofa P�PERT�►. A'DSp,��1.T '�'P..pP'�SZT��5 L11a�-1VO�t�[IS - <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well > ft. <br /> Irrigation Well I . nno 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)?YESM NO[] 500 Cilg'F- is ,MsrauE-p <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 <br /> Mailing Address o Q <br /> Day Phone Number(-9?-s } -7 <br /> - I L_9 ZZ-00S . .... <br /> SignatAre Title Date <br /> EH 23 046(Revisedl0/16/03) Page 6 <br />