Groundwater Appropriation Permit Application Page 1 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES ======== DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION 45 MARS HILL FREDERIKSTED, ST. CROIX, VI 00840 PHONE: (340) 773-1082, FAX: (340) 773-9310 APPLICATION FOR GROUNDWATER APPROPRIATION New______ Renewal_____ In compliance with Title 12, Chapter 5, Virgin Islands Code, the undersigned ______________________________________________________________________________ Name of Property Owner ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Mailing Address ______________________________________________________________________________ Telephone Number Hereby applies for a permit to appropriate groundwater. 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): 1. Domestic______  Number of apartment’s: ______________________  Number of people to be served: ________________ 2. Farm Operation_______ Groundwater Appropriation Permit Application Page 2  Land acreage reserved for crops: _________________________________  Type and number of livestock: ___________________________________ 3. Commercial (water sales)______  Estimated water production: ______________gal/day  Proposed cost of water at site: _____________per 1,000 gal. 4. Municipal ___________  Area to be served: _______________  Estimated population to be served: ___________________ 5. Other (laundry, etc.) __________  Details: _________________________________________ Planning for Development (explain the use of the water): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Estimated quantity of water proposed to be extracted daily: ____________ gal/day Name of proposed Driller & License Number (if applicable): __________________________ Fee of $10.00 is attached. (If 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 INSPECOR: ___________________________________ GROUNDWATER APPROPRIATION PERMIT NUMBER (if approved): ______________