Louisiana Administrative Code › Title 46 - PROFESSIONAL AND OCCUPATIONAL STANDARDS › Part LXXXIX - Water Well Contractors (Drillers) › Chapter 11 - Revocation; Hearings; Appeals › Section LXXXIX-1111 - Forms

Current through Register Vol. 50, No. 6, June 20, 2024
A. Application for
				Louisiana Water-Well Contractor's (Driller's) License
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				license ever been revoked or suspended by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.