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li'lo'96 i^:2� NO.108 D04 <br /> What is the depth to groundwater" ,_ <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent Properties" YES NO Y7 <br /> TYPE of WENS DLSTANCE To TANKS(S) <br /> Public Well All 1+ R <br /> Private well )./ # ft. <br /> Irrigation Well /T ft. <br /> Monitoring Well L/ ft. <br /> Other U JI" ft. <br /> id. Will the tank(s) pending closure be replaced with an abovegrooad or tnderp°wd storage tank(s)" YESe'Nol j <br /> 15. indicate the responsible party to be billed for additional PHS-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. proPcrty <br /> owner, the party must acknowledge this responsibility for the billing by signature sad date below. <br /> ` <br /> Name d +f v.,.- <br /> M S Rd 's <br /> Mailing Address of J CSC fON C Q✓�iS <br /> Day Phone Nuwber /2�) <br /> Si <br /> Title <br /> FX 23 046 (Revised 9/11/96) page 6 <br />