Laserfiche WebLink
3 <br />12. What is the depth to groundwater? <br />Describe the source of information: w <br />13. <br />14. <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANWS) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />LIM922 <br />Will the tank(s) pending closure be replaced with an abovcgroand or underground storage tank(s)? YES[ I NO* <br />15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br />permit payment per tank. If the party designated. below is different than the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name n <br />Mailing Address I�j��1�if��Z�1f�lr'i/►l:��r�o�.����_�.�.�__ <br />Day Phone Number r� <br />pe. <br />Title <br />EH 23 046 (Revised 9/11/96) Page 6 <br />]- 12— 6 P <br />Date <br />5/-170/q1 <br />