Laserfiche WebLink
12. <br />13. <br />14. <br />15. <br />r <br />What is the depth to groundwater? eo�tr2 rs C?=�® <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? YESNO [ ] <br />TYPE OF WELLS <br />DISTANCE TOT S) <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 />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO <br />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 Xr r 1 /C <br />79111 <br />Mailing Address �'� r % ^ a®6N"Z/f/GG l®.6 <br />Day Phone Number( Q6 0 ) '�/— 3 4 <br />Signature Title <br />EH 23 046 (Revised 9/11/96) Page 6 <br />,' 47 7 <br />Date <br />