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1i16%92 '_7: <br /> N0. 102 DC4 <br /> 12. What is the depth to groundwatez' p <br /> Describe the Source of information. !qO' <br /> D i <br /> 13. Are there any water wells on this parcel or adjacent properties" YES NO <br /> TYPE Oir WELLS DISTANCE TO TANWS) <br /> Public Well 1/4 R <br /> Private Well u ? It. <br /> Irrigation Well ? fe <br /> Monitoring Well (f MOther (//A ,z <br /> 16. Will the tanks) pending closure be replaced with an r,bovegrooad or oadcrg oned storage tank(s)? YESW�Nol I <br /> Is. indicate the responsible party to be billed for additional PHS•EHD staff time expended beyond 3 hour minimum <br /> permit payment per took. if the party designated below is different than the permit applicant, a& property <br /> owner, the party must acknowledge this responsibility for the billing by sigoature and date below, <br /> Name d t V;c,e M <br /> Mailing Address 1j075 YL(Gi J JC fON. 9,5215 <br /> Day Phone Number (�17�1 )G�C —L 7� <br /> SI <br /> Title <br /> EH 23 046 (Revised 9111/96) Page 6 <br />