LAC 46:LXXXIX.1111. Forms

A. Application for Louisiana Water-Well Contractor's (Driller's) License Editor's Note: The telephone number listed in §1111.A has been changed to (225) 274-4172.* DEPARTMENT OF TRANSPORTATION AND DEVELOPMENT WATER RESOURCES SECTION P.O. BOX 94245 BATON ROUGE, LA. 70804-9245 Telephone (225) 379-1434 For Office Use Only License No. WWC______ APPLICATON FOR LOUISIANA WATER WELL CONTRACTOR'S (DRILLER'S) LICENSE PLEASE PRINT IN INK OR TYPE WHEN COMPLETING THIS FORM APPLICANT: Name_____________________________________________ Birthdate:_______________________ Mailing Address____________________________________________________________________ City, State, Zip___________________________________________________________________ Social Security Number_____________________________________________________________ Telephone No. and Area Code________________________________________________________ BUSINESS: Firm's Name (to appear on license)_________________________________________________ Located at_________________________________________________________________________ City, State, Zip___________________________________________________________________ Telephone No. and Area Code________________________________________________________ TYPE OF BUSINESS: Water Well ______, Monitoring Well ______, Heat Pump Well or Hole _________, (Check one or more) Geotechnical Borehole_______, Plugging Well or Hole______, Other_________ EXPERIENCE RECORD: (a) Date started drilling:_____________________________________________________________ (b) Approximate number of wells or holes drilled during the last calendar year:________ (c) Depth of deepest well or hole actually drilled during career, in feet:_____________ (d) Largest well or hole drilled during career, in inches:_____________________________ (e) Are you presently licensed by another state? Yes___ No___. If yes, name State______ (f) If previously licensed, has your drilling license ever been revoked or suspended by any State? Yes___, No___, Not Applicable_______. If yes, please explain the details on separate sheet. DESCRIPTION OF DRILLING EQUIPMENT: Drilling Rig Make Capacity (depth in feet) Owned or Leased ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ REFERENCE: List two licensed drillers familiar with your work experience. (1)________________________________________________________________________________ (Name) (Mailing Address) (License No.) (2)________________________________________________________________________________ (Name) (Mailing Address) (License No.) Do you or your company have liability insurance? Yes _____ No _____. If yes, what amount? $___________. Name of Insurer_____________________________________ Date expires________ I affirm that I have two years of drilling experience under the supervision of a licensed water well contractor or other comparable drilling experience acceptable to the Department. My drilling experience was with___________________________________________________________________________________________ (Name) (Mailing Address) (Telephone No.) from the time period__________ to _____________. (Additional experience may be listed on the reverse side of this form.) I hereby grant my reference and insurer the authority to provide the Louisiana Department of Transportation and Development with information necessary to establish my qualification for a driller's license. Yes _____ No _____. I also affirm that I meet qualifications for a license as spelled out in R.S. 38:3098 through 38:3098.8 and that I will fully comply with all rules and regulations for wells and holes promulgated and to be promulgated by the Louisiana Department of Transportation and Development, Office of Public Works. Yes ____ No ____. Enclosed is check or money order no. ______________ dated ___________ in the amount of $_____________ for license fee, made payable to the Department of Transportation and Development. CERTIFICATE: STATE OF LOUISIANA PARISH OF _____________________ BEFORE ME, the undersigned authority, a Notary Public duly commissioned and qualified within and for the State and Parish aforesaid, personally came and appeared________________________________________________, who being by me first duly sworn, did depose and say: That the information contained and set forth in the above and foregoing APPLICATION FOR LOUISIANA WATER WELL CONTRACTOR'S LICENSE is true and correct, to the best of my knowledge, as stated herein. _________________________________________________ APPLICANT Sworn to and subscribed to before me this ____ day of __________________________________, 20_____ at ______________________________________, Louisiana. _________________________________________________ NOTARY PUBLIC B. Application for Renewal of Louisiana Water-Well Contractor's (Driller's) License Editor's Note: The telephone number listed in §1111.B has been changed to (225) 274-4172.* DEPARTMENT OF TRANSPORTATION AND DEVELOPMENT WATER RESOURCES SECTION P.O. BOX 94245 BATON ROUGE, LA. 70804-9245 Telephone (225) 379-1434 APPLICATION FOR RENEWAL OF LOUISIANA WATER WELL CONTRACTOR'S (DRILLER'S) LICENSE PLEASE PRINT IN INK OR TYPE WHEN COMPLETING THIS FORM APPLICANT: NAME_______________________________________________________________________ MAILING ADDRESS____________________________________________________________ CITY, STATE, ZIP___________________________________________________________ SOCIAL SECURITY NO.________________________________________________________ TELEPHONE NO. AND AREA CODE________________________________________________ BUSINESS: FIRM'S NAME________________________________________________________________ LOCATED AT_________________________________________________________________ CITY, STATE, ZIP___________________________________________________________ LICENSE No. WWC-___________________________________________________________ TELEPHONE NO. AND AREA CODE________________________________________________ DRILLING RECORD: For categories listed below, indicate the total number of wells or holes which you (your company) drilled and/or plugged during the past twelve months: Category No. Drilled No. Plugged a) Domestic water wells ___________ ___________ b) All other types of water wells ___________ ___________ c) Monitoring wells ___________ ___________ d) Heat pump holes ___________ ___________ e) Geotechnical boreholes ___________ ___________ RENEWAL FEES: Enclosed is check or money order number ______________________________ in the amount of $_____________ for my annual renewal fee. NOTE: Your annual renewal fee is $100.00, unless you drill only domestic water wells (as defined in LAC 70:XIII.111) and you drill less than 25 domestic wells annually, in which case the renewal fee is $50.00 I certify that the information contained and set forth in the above and foregoing application for renewal of Louisiana water well contractor's license is true and correct, to the best of my knowledge, as stated herein. ________________________________ Signature ________________________________