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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