La. Admin. Code tit. 46 § LXXXIX-1111
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:
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.
(Name) (Mailing Address) (License No.)
(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
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:
CategoryNo. DrilledNo. Plugged
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
________________________________
Date
La. Admin. Code tit. 46, § LXXXIX-1111