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12. <br />13. <br />What, is the depth to groundwater? _ UlN kN e <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS DISTANCE TO TANKS(S) 7.1 <br />Public Well ft <br />Fritrata WP11 ft_ <br />Irrigation Well <br />ft - <br />Monitoring Well <br />ft. <br />Other <br />It. <br />YES [ I NO I I <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[ ] <br />15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br />per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />Name L. L_ S c iLv C C -,S <br />Mailing Address _S 2- <br />7 �' <br />Day Phone Number ( -5 e1 <br />-1 q - 1 130 <br />Signature Title <br />EH 23 046 (Revised 08/13/99) Page 6 <br />3-2.16 - 0 l <br />Date <br />0I�'/z <br />