HomeMy WebLinkAbout214996 12/04/2012 «��,F CITY OF CARMEL, INDIANA VENDOR: 074600 Page 1 of 1
ONE CIVIC SQUARE DEPT OF NATURAL RESOURCES CHECK AMOUNT: $200.00
�?o CARMEL, INDIANA 46032 DIVISION OF WATER
.off`o. 402 W WASHINGTON ST W264 CHECK NUMBER: 214996
INDIANAPOLIS IN 46204
CHECK DATE: 12/4/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 MASCARI 100 . 00 OTHER EXPENSES
601 5023990 RANSFORD 100 . 00 OTHER EXPENSES
APPLICATION FOR WATER WELL DRILLING LICENSE Return to:
AND PUMP INSTALLER LICENSE
INDIANA DEPARTMENT OF NATURAL RESOURCES
' n
'• %'', State Form 417(R3/11-10) /v DIVISION OF WATER
402 W.Washington St.,Room W264
Approved by State Board of Accounts,2010
l n Indianapolis,IN 46204-2641
�Y
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: 7; 77- Aa
(First) (Middle) (Last)
Business Address: 35e�-0 Gt, -I
((S Street or Rural Route)
C�im,-1 190 71/
(City) (State) (ZIP code)
Office Telephone Number: J/7 - 733 - PS-.SS Email Address: L/_— _
(Include area code)
Date of Birth: /O-/9- / 9& j
Type(s) of Equipment Operated or Installed: D
cl
Number of Years Operated:
Employment History (as a water well driller or pump installer):
Company Name / Company Address Employment Dates
d"n c
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, and com
Signature: Date:
Name of Co
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
AND PUMP INSTALLER LICENSE INDIANA DEPARTMENTfOF NATURAL RESOURCES
a e State Form 417(R3/11-10) DIVISION 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. (!C 25-39-3-3).
Full Name: `7-0 k✓\ ,�✓1+ko Ali
(First) (Middle) i
(Last)
Business Address: 3 qs0 w
(Street or Rural Route)
(City) sJ x/(007
_ (State) (ZIP code)
Office Telephone Number: �31-71 7 3 3 _2- S�S
(Include area code)
Email Address: SC4r1 Ez
i
Date of Birth:
Type(s)of Equipment Operated or Installed:
Number of Years Operated:
Employment History(as a water well driller or pump installer):
Company Name Company Address
Employment Dates
�y Of /via 1 5�
171aY 1i -Y10 /n Za92—
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).
/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,�and complete.
Signature: _..._.
Date:
Name of Coy pany: G
r
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:
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 11/26/2012
INDIANAPOLIS, IN 46204-2641
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
11/26/201: MASCARI $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
r)/.V 2/z in,
Date Officer
VOUCHER # 122853 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
MASCARI 01-6750-02 $100.00
Voucher Total QC.C)C) V"1121P
Cost distribution ledger classification if
claim paid under vehicle highway fund