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Home My WebLink About305951 12/12/16 .- ��'`'� CITY OF CARMEL, INDIANA VENDOR: 074600 ONE CIVIC SQUARE DEPT OF NATURAL RESOURCES CHECK AMOUNT: $ 200.00 ,� _� CARMEL, INDIANA 46032 DIVISION OF WATER CHECK NUMBER: 305951 •y,�oN_ 402 W WASHINGTON ST W264 CHECK DATE: 12/12/16 INDIANAPOLIS IN 46204 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 122016 200.00 OTHER EXPENSES co N N E ca 0 OD U- Fr O ' U W D � O Z ~ s Q Q � o 0 z cn o D IJ N U 2 Z (V N Cl)O 141 v m c� � OC Z cc) 4wLu 0 a d rn co 0 LL O v ami LL E I- D a/ ZOO D U co o o -a LU U- z0= OOH ¢ U Z N Ci L pato7Q Z `' v a � ooOvZ O a o 'c��o U � Division of Water MR Attn: Monique Riggs 402 W. Washington St., W264 Indiana Department of Indianapolis, IN 46204-2641 Natural Resources Toll-free (877) 928-3755 RENEWAL OF INDIANA WATER WELL DRILLING & PUMP INSTALLER LICENSES FOR 2017 —A Reminder for All Well Drillers & Pump Installers Who Operate in Indiana— It is time to renew your Indiana water well drilling and/or pump installer license, or the licenses for drillers or installers you employ, for the calendar year 2017. 2016 licenses are valid until December 31, 2016. Although there is no penalty for sending in a 2017 renewal application and fee after December 31st, please note that a current 2017 license is required before installing any wells or pumping equipment on or after January 1, 2017. CHECK THE DATE on your license—see below if your most recent license expired in **2015 ** Application forms for renewal are enclosed. If you need additional copies, please copy the form or download it from the Division of Water website at: http://www.in.gov/dnr/water/2450.htm • The signed application form is required for renewal, but license renewals do not require reference statements or employment histories. • Please send the application form with a check or money order payable to Indiana DNR for the one-year renewal fee of one hundred dollars to the address shown at the top of the page. • The fee of$100.00 is the same for a well driller only,pump installer only,or a combination license. • DNR must receive both the form and the fee in order to issue an updated license. • The fee is not pro-rated for licensing during only part of the year. • Cash or credit card is acceptable for payment in person at the DNR Customer Service Center at the Indiana Government Center South (see the address above). ATTENTION ALL WATER WELL DRII,LERS AND PUMP INSTALLERS! Continuing Education requirements are due as a condition of renewal for your 2017 license! Please see the back of this letter for a listing of the hours on file for you or your licensed employees. If you have held your license for less than a year as of 12/31/2016, you are not required to meet the continuing education require- ments until the next two year cycle that ends 12/31/18—Your continuing education hours will be shown as na on the back of this letter. (Hours listed are as of 11/14/16) See the listing of available approved Continuing Education courses on the Division of Water website at: http://www.in.gov/dnr/water/6110.htm **Did our most recent license expire December 31,2015?** An individual with a 2015 license who has not renewed it for 2016, but wants to remain licensed in the future has until December 31, 2016 to apply &pay for the 2016 license before it is considered lapsed. If you do not obtain a license for 2016, you cannot later renew your licensed status for 2017 simply by paying the fee. When more than one year passes before you renew an expired license, you must re-take the written competency examination in order to be re-licensed. You may not avoid obtaining continuing education by allowing your license to lapse, and then re-testing. Proof of earned hours for the year they were due will still be required. Avoid any inconvenience! Keep your license and continuing education up to date! When your address changes—If your company changes its name, address, or phone, please notify the Division at 317-232-4160, Option 4. Also,please advise the Division if a licensee you employ leaves the company, and please advise the licensee to provide a new address to the Division. Renewal reminders cannot be sent to unknown addresses. Thank you!! 0DIVI�`r'3 APPLICATION FOR WATER WELL DRILLING LICENSE Return to: AND PUMP INSTALLER LICENSE INDIANA DEPARTMENT OF NATURAL RESOURCES e e State Form 417(R3/11-10) SION OF WATER °" Approved by State Board of Accounts,2010 402 W.Washington St.,Room W264 Indianapolis,IN 46204-2641 The provisions of IC 25-39 require anyone who operates water well drilling or driving equipment and engages in the drilling of water wells, or the installation or service of water well pumping equipment in Indiana to have a valid Indiana Water Well Drilling or Pump Installer License. To qualify for an Indiana water well drilling license or pump installer license, an applicant must be at least eighteen (18) years of age, successfully complete a competency examination, and provide three reference statements to the Division of Water, of which at least two must be from a licensed water well driller/pump installer or a licensed plumber. (IC 25-39-3-3). Full Name: j�j/ (First) (Middle) (Last) Business Address: J /5-0 G✓ /� /J7- (Street r(Street or Rural Route) (City) (State) (ZIP code) Office Telephone Number: .�/J' 73�Z�s'.S Email Address: (Include area code) Date of Birth: /0-/9-/gam 3 Type(s) of Equipment Operated or Installed: VPS'Y7�Cr /Number of of Years Operated: Z� Employment History (as a water well driller or pump installer): Company Name f/ Company Address Employment Dates The annual fee for a water well drilling/pump installer license is one hundred dollars ($100) for a calendar year; whether it is for one or both endorsements. Please make your check or money order payable to the DEPARTMENT OF NATURAL RESOURCES (or simply DNR). I hereby swear or affirm under the penalties for perjury that the information submitted herewith is, to the best of my know- ledge and belief, true, accurate, of complete. Signature: Date: //Z-9-ZO/b Name of Company: Note: An application for an original license is not complete until three(3)reference statements are completed and received by the Division of Water. FOR ADMINISTRATIVE USE ONLY Date Application Was Received: Application No.: License Number Issued: Issued By: APPLICATION FOR WATER WELiL DRILLING LiCENSE Rotumto: AND PUMP INSTALLER LICENSE INDIANA DEPARTMENT OF NATURAL RESOURCES State Forth 1/11-10) DIVISION OF WATER Approved byy Slate fe Board of Accounts,2010 402 W.Wastdngton St.,Room W264Indlanapolls,IN 462042841 The provisions of 10 25-39 require anyone who operates water well drilling or driving equipment and engages In the drilling of water wells, or the installation or service of water well pumping equipment in Indiana to have a valid Indiana Water Well Drilling or Pump Installer License. To qualify for an Indiana water well drilling license or pump installer license,an applicant must be at least eighteen (18)years of age, successfully complete a competency examination, and provide three reference statements to the Division of Water, of which at least two must be from a licensed water well driller/pump installer or a licensed plumber. (IC 25-39--3-3).Full Name: JZ� l446) h (First) (Middle) (Last) Business Address: 3 � � W r 3 1 5T- (Street or Rural Route) (City) (state) (ZIP code) Office Telephone Number: 0317) 733-- U!55-- Email Address: 'j Me,5 4a.^v1.T• Gam✓ (include area code) Date of Birth: 1!5--/Y-��- Type(s)of Equipment Operated or installed: V(2-r14OL° -T,- Number r ;n v �. Number of Years Operated: 7 Employment History(as a water well driller or pump Installer): Company Name Company Address Employment Dates '-9Y` t a /'.tick t r v�`�.2_ �£�ar� yocoL_ �ie5d.t� The annual fee for a water well drilling/pump installer license is one hundred dollars($100)for a calendar year;whether It is for one or both endorsements. Please make your check or money order payable to the DEPARTMENT OF NATURAL RESOURCES(or simply DNA). i i hereby swear or affirm under the penalties for perjury that the information submitted herewith Is, to the best of my know- ledge and belief, five,accurate,and complete. r`-- Signature: Date: Name of Company: G�`��j d r (.a r�+�►e Note: An application for an original license Is not complete until three(3)reference slatements are completed and received by the Dlvlslon of Water. FOR ADMINISTRATIVE USE ONLY Date Application Was Received: Application No.: License Number Issued: Issued By: