DERSION OP

DERSION OP ENVIRONMENTAL PROTECTION PH I FAX GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION CYRIL E: KING AIRPORT TERMINAL BUILDING, SECOND FLOOR ST. THOMAS, U.S. V.I. 00802 APPLICATION FOR GROUND WATER APPROPRIATION New K Renewal K In compliance with Title 12, Chapter 5, V.I. Code, the undersigned: (Name of Property Owner) (Mailing Address) (Telephone #) hereby applies for a permit to appropriate ground water. The well(s) will be located at: (Estate, Lot Number and Island) (Property Tax Number) (Well Drilling Permit Number•) • = if applicable Proposed use of well(s): Check ONE use only. DOMESTIC 0 Number of apartments Number of people to be served EFTA00798203 C Application for Ground Water Appropriation Page 2. FARM OPERATION K Land acreage reserved for crops Type and number of livestock COMMERCIAL (WATER SALES) K Estimated water production Gallons per day Proposed cost of water at site Per 1,000 gaL MUNICIPAL K Area to be served Estimated population to be served OTHER (Laundry, etc.) K Details Plan for development, or use of the water including the capacities of any proposed impounding reservoirs, cisterns, storage tanks, etc. Estimated quantity of water proposed to be extracted daily: Gallons. Name of proposed Driller & License Number: David Muhammad - Lic. No.: WDL-016-003 Fee of $10.00 is required and should be attached. (If paying by check, please make payable to the Government of the Virgin Islands). Signature of Property Owner Date FOR DEPARTMENT USE ONLY: DATE: APPROVED: DISAPPROVED: REMARKS and/or SPECIAL CONDITIONS: SIGNATURE OF WELL INSPECTOR: GROUND WATER APPROPRIATION PERMIT NUMBER (if approved): SwaicinfOrdYPcd 2/2001 EFTA00798204