Well Driller License App
SEWE BY:VIDPNR/DEP-watergit 3 d= - 3 s11518AM ; VIDPNR/DEP-Water gut if 2/ 8 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 0 Department of Planning & Natural Resources Division of Hnviranmental Protection 45 Mars Hill Frederiksted, St. Croix, U.S.V.1. 00840-4474 pilin: (340) 773-1082 APPLICATION FOR WELL DRILLER'S LIC] (340) 773-9310 In accordance with the provision of Title 12, Chapter 5, Section 157, V.1. Code (as alefidi8a-27*4 11/28/87). I hereby apply for a Well Driller's License and enclose herewith check/cash in the amount of Twenty-five Dollars ($25.00) in payment of license fee. (If Check, please make payable to the Government of the Virgin Islands). The following information is furnished in support of this application: FULL NAME....cccccecccccssosccaesescnseeces “icaeedk LL acdaananenesescesonsarssccenanacasecessocensesecssucessace DATE OF BIRTH CITIZEN OB .uccccscccessectovvcacscocceseceassoscesvscescaesesdsonccesscessassesseacessouaceseecsetscavevesseareuseece .RESIDENT OF... …
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SEWE BY:VIDPNR/DEP-watergit 3 d= - 3 s11518AM ; VIDPNR/DEP-Water gut if 2/ 8 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 0 Department of Planning & Natural Resources Division of Hnviranmental Protection 45 Mars Hill Frederiksted, St. Croix, U.S.V.1. 00840-4474 pilin: (340) 773-1082 APPLICATION FOR WELL DRILLER'S LIC] (340) 773-9310 In accordance with the provision of Title 12, Chapter 5, Section 157, V.1. Code (as alefidi8a-27*4 11/28/87). I hereby apply for a Well Driller's License and enclose herewith check/cash in the amount of Twenty-five Dollars ($25.00) in payment of license fee. (If Check, please make payable to the Government of the Virgin Islands). The following information is furnished in support of this application: FULL NAME....cccccecccccssosccaesescnseeces “icaeedk LL acdaananenesescesonsarssccenanacasecessocensesecssucessace DATE OF BIRTH CITIZEN OB .uccccscccessectovvcacscocceseceassoscesvscescaesesdsonccesscessassesseacessouaceseecsetscavevesseareuseece .RESIDENT OF... evesturvesersaeoseauesssecuessitbspaussstenssasavncanes sssteecavacseceucqunesessavoccarsevece HOME ADDRESS. ...csccccccssssovccssesssctssssssececsscesersassreneransnssseassceasuvs sccevecssoseesvsereeseuces MAILING ADDRESS ......cccccccccssacssesauecsestasnteccesovscvsvscaeoesocnvenceesucevsvecesseusustsasssseeeses BUSINESS ADDRESS.....c.cccccccsessscscossscssscossusoncecesestccssrsssncacseasecsososvssrsusvccensveveveces PRESENT TYPE OF BUSINESS ACTIVITY, IF ANY ..c.cccccccsccuscccorenseessnssesseanerss SAC COSTE SHE T OCHRE UE SH MAA TTA DE ESEGTOEUSHEOEDD davscvocseenncdsebrdariveauepesneneanocsvouesspenneonsvedsnosetareascencecesouce S4aVDooogns ooepvea COO vad OO OG KT OPFVIRIOOUDEAAUGEOTOONARS Gaacane oo EDUCATION: ( ) 12TH GRADE ( ) COLLEGE - DEGREE.....sssssssee LIST PROFESSIONAL OR TECHNICAL EXPERIENCE DURING LAST FIVE YEARS (LATEST FIRST): INCLUDE ANY SPEC TFIC EXPERIENCE IN WELL DRILLING. Employer's name Type of | Position Period of Business Classification. REMARKS (IF ANY) CONCERNING PROFESSIONAL OR TECHNICAL BXPERIENCE?....cccsccsssssensossesopsccevovecnesssisoveedsevecesseavsbacsresentsarceseenesssseeseytaes ceoeee 9G00CnDCG0Cs POGRY uvoteoun Fado OOOH GSERGELSHOHOGAEODDAEE GOR EDSIDGOSGSGOORD VEG HUGT HOGS RS OBEN ER EROEUBTBATE TOSSED HOU DHOAEDEDOEAODOHAOED OOO TOUOATOUPHUS HD OUT COUTATLOS POUND EGA re) BI -VIUPNR/ Uo" Wwa Ler eu y Om U7 D shh LOAM + VAUEINN/ UE Wa Ler gu VF Jf J CHARACTER REFERENCES PROFESSIONAL REFERENCES (Other than relative of applicant) NAG... .ccccecvcevancove cagueravoga bevencous Wamoe... BODSEOHODODHEEOGTIOOOCOTAHDOCENO SOOM IESEUOSOD Address evar veoDOaEvevOU OT OEE BO aeTEo HOSE ECEO AGreSS....10:scccccosscersorscsrcccservocenceenes WUC OCTLMBSVUTHTO ESAS SUATAGUEGDAHLDDEAOSRATL pood soeedaguae denguGoos GG ETO SUSE POOR O PS BOUE Eh EB EE BEReoheAD Name PoHT CEH BOGE BA SHE SANGO FHSOoESHeDeEEDoDASS N@e.....cceccccccoccessceeuecseveceneosecocanseees Address Address QsIrvepserTseUTT ABS OS TPE ORE OOGEeAesHeedseeooe Gedo Co PuaeloGodUNGevusT ODO OVO Eee POU eee Peon anan BAGAGTNOTGAIDOT GVO LOS eoewodane fob Signature of Applicant Territory of the Virgin Islands Municipality of: Subscribed and sworn to before me this.....,....day of... eeCurtmacbverrvenoPooe 199... cece Notary Public FOR DEPARTMENT USE ONLY: ( APPROVED ( DISAPPROVED If Disapproved, @1V6 TEASOD........:..-ccsrscscvccevsecsssevccseycensveeeesaecessareeosarsuceessucessuvestsceerteves CODFETOON AT POVE EO ET YEOH EUSTUGOREAIN OUTS IA TTES PTE PONICDEHTAGEROTHGDGREHOGEHURSDDUEHLOOTFEASHEOD DHOGODEOOCADDEOOGHOO SOE OL DAAVdOaTOvIDD Business License Current:( ) YES ( ) NO saraser Date Signature Well Drilling License Number (if approved):