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' 12. What Is the 6epth to groum*W" <br /> #4*` <br /> Describe the gouda of In <br /> t t, Are there any water well• ell tbb pGK%l be. adlK*M pMpgHlt!!} y�g � ) NO ( 1 <br /> TYPR Off 1' RU A 918TAmeN topAMM , <br /> Peblle Wi11 R, <br /> Prt.ate VI►eM R, <br /> Irrigatte"Well p, <br /> Monitorl_ Well R, <br /> Other ,.. R. <br /> t4. Will the tank(s) pending clofe be replaced with 1111 •be1@00end or nnderdromW storage tank(s)f YES( j NQ( ) <br /> tS. Indicate the r"penNble p rl1 to be billed fm Ndltletlal M MATIb staff tlme expended beyond 3 hour minimnnt <br /> permlt payment per tank. V No pMy des4"ted bdW k thye nt than the permit applift"4 e.16 property owner, <br /> the party mist aekimledge MY 11UPMANIIy bf IM bpilhb by tlgnature and date below <br /> Nome_ _C' _-�-� 1 5 � l X11 �•S ( C� i [ ' `� <br /> M1lalling Address "1 "� �i.� `� i - .�� k- (' <br /> Day Phone Number <br /> Slgnatnr� 1 bete <br /> Page 6 <br />