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12. 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 [rj NO [ ] <br />'ITI'1, OF WI,LIIS 1)ISTANCI, T�TANK�S(S) <br />t� <br />public Well <br />� /DD. t) <br />f►• <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />< SO <br />ft. <br />Other <br />R. <br />l2Ccu 3 <br />with an u1H)vr Uround o undo round torn a tank(s)? YF.S� [ ) <br />WIII the tank(s) puuling closure be rcpl)Iccd) itl �, rl, t; <br />Indicate the responsible purty to be billed for additional PIIS-LiID staff tune expended beyond 3 hour ntlnlu),;ut <br />Permit payment per tank. if the party designated below is different than the permit applicant, e.g. property owner, <br />the pill �........�...1.... )l.ic r�•cntincihSltiv r1)r' the I)llllllt, by siLnature and date below. <br />Name <br />L. <br />Mailing Address 64 7-1 I -LW,�_ <br />Day Phone Number) <br />ignnture <br />Page 6 <br />Date <br />a <br />