HomeMy WebLinkAbout203826 11/21/2011 CITY OF CARMEL, INDIANA VENDOR: 074600 Page 1 of 1
ONE CIVIC SQUARE DEPT OF NATURAL RESOURCES
0 �I' CARMEL, INDIANA 46032 CHECK AMOUNT: $200.00
DIVISION OF WATER
402 W WASHINGTON ST W264 CHECK NUMBER: 203826
INDIANAPOLIS IN 46204
CHECK DATE: 11/21/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 2 200.00 MISC EXP -WATER TRMT -O
APPLICATION FOR WATER WELL DRILLING LICENSE Return to:
AND PUMP INSTALLER LICENSE I °IANA oEP �DI�VISIO OF WATER NATU RAL RESOURCES
State Form 417 (R3 11 -10) 402 W. Washington St, Room W264
Approved by State Board of Accounts, 2010 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: ��TT
(First) (Middle) (Last) i
Business Address_: j 'V5 0 LJ
/I (Street or Rural Route)
07-
(City) (State) (ZIP co de)
Office Telephone Number. 2 733 Z PS Email Address: 6n aAx �s�l .."O iii
(Include area code)
Date of Birth: /'r -/9
Type(s) of Equipment Operated or Installed:
Number of Years Operated:
Employment History (as a water well driller or pump installer):
Co mpany Name Company Address Employment Dates
q 5 GJ
The annual'feefor 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, a om fete.
Signature: Date:
Name of Company C 4 1/r droyev Deea
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 WELL DRILLING LICENSE Return to:
AND PUMP INSTALLER LICENSE INDIANA DEPARTMENT OF NATURAL RESOURCES
State Form 417 (R3 11 10) DIVISION OF WATER
Approved by State Board of Accounts, 2010 402 W. Washington St, Room W264 5 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 2- 3--9 -3 -3).
rr
Full Name: �10V h
(First) (Middle) (Last)
Business Address: 3 'IMG n 6 7
(Street or Rural Route)
7V
(City) (State) (ZIP code)
Office Telephone Number: 317 73 3-, 2-19 5 6 5z Email Address: J nlG a Q C�i¢.►rFL
(Include area code)
Date of Birth: 60Z
Type(s) of Equipment Operated or Installed:
'Number of Years Operated: Z
Employment History (asa water well drillerorpump installer):
Company Name Company Address Employment Dates
rtJ00
!'he annual fee for a water well drilling /pump installer license is one hundred dollars ($100) for a calendar year, whether it is
:)r one or both endorsements. Please make your check or money order payable. to the DEPARTMENT OF NATURAL
.ESOURCES (or simply DNR).
hereby swear or affirm under the penalties for perjury that the information submitted herewith is, to the best of my know
dge and belief, true, accurate, and complete.
mature:
Date:
me of Company: O C oe r'Ae
r. 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
Application Was Received: Application No.:
se Number Issued Issued By
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
74600
DEPT OF NATURAL RESOURCES Purchase Order No.
DIVISION OF WATER Terms
402 W WASHINGTON ST W264 Due Date 11/14/2011
INDIANAPOLIS, IN 46204 -2641
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
11/14/201' JOHN M $100.00
I hereby certify that the attached invoice(s), or bill(s) is (are) true and
correct and I have audited same in accordance with IC 5- 11- 10 -1.6
Date M
VOUCHER 112964 WARRANT ALLOWED
74600 IN SUM OF
DEPT OF NATURAL RESOURCES
DIVISION OF WATER
402 W WASHINGTON ST W264
INDIANAPOLIS, IN 46204 -2641
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
JOHN M 01- 6750 -03 $100.00
M I 1I 1Q>
Voucher Total J00 DD ,F
Cost distribution ledger classification if
claim paid under vehicle highway fund