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PIJG-24 9H 0i:52 FROM:HJLAID FhLL)MLLL Cloy D77-C7U'b �"•cc+� - �"-�-' - <br /> 08-21-19% 02:51FM FP91 :-EMG'D TO 5932506 P.03 <br /> it <br /> i <br /> 12. wb,t is the depth to �,Mntldwa=? ?-b' <br /> j 'be th ounce of informs o• 1 <br /> es �. CNet is ✓*vLEI ss3 <br /> I <br /> 13. Are Itbtlre aoY wafer wNla On this A*r^Ti Pr'"Perdes' <br /> I, <br /> !I TYPE OF WYLLS DMTANCE TO TARXS(S) <br /> Public wril R <br /> I• _ <br /> Private well <br /> Trrigatinn well R <br /> Monitoring Weil- —. __.... R <br /> i i Oefier R <br /> �i <br /> it <br /> 14. wi�l!the tnok(s) peading thcore ix replaced with in abovegtaand or andergrMad storage tank(s)? YES[ i NO( I <br /> I� <br /> 15. Ind ate the responsible jYtrty to t>e billed r.,. ;,Ja7itiv...i l'i't IF.Y;ri stall time=poaded beyond 3 boor minimum <br /> per ll payment per tick. If the party destgnareti ttelow is diRerear than rhe permit appi1=11t, eg, property <br /> ow er• the party must acloo�rjedea this res(•nttsihiflty Cor the billing by signature lad date below. <br /> 1Ut{&jG� O(l> L <br /> Na� <br /> Ma'tingAddress tL37� ttT,. S'z"l. r!_!_`..I�t) l". �lSjtO�7'-Z•7�13 <br /> DJPhone Nomber ( <br /> 1 <br /> Jtg a Title _� Date <br /> I <br /> 1` <br /> I� <br /> I <br /> ! <br /> j I <br /> EH 23 046 (xtrvised 4111196) MBe o <br /> I <br /> I <br /> TOTAL F.93 <br /> 08-24-1998 07:30RP1 209 599 2506 P•03 <br />