Form MO780-1731 "Contractor and Apprentice Permit Application" - Missouri

What Is Form MO780-1731?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-1731 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

ADVERTISEMENT
ADVERTISEMENT

Download Form MO780-1731 "Contractor and Apprentice Permit Application" - Missouri

Download PDF

Fill PDF online

Rate (4.8 / 5) 50 votes
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
MISSOURI GEOLOGICAL SURVEY
NON-RESTRICTED RESTRICTED RESTRICTIONS
CONTRACTOR AND APPRENTICE PERMIT
WATER WELL
TEST HOLE ONLY
PUMP
TEST HOLE ALSO
APPLICATION
MONITORING WELL
PROBATION
HEAT PUMP
PERMIT NUMBER
CHECK NO.
NOTE: THE CONTRACTOR AND APPRENTICE TESTING
APPLICATION AND EXAM MUST BE COMPLETED PRIOR
TEST SCORES
TEST DATE
TEST ID
TO SUBMISSION OF THIS FORM
GEN
/
DATE RECEIVED
DATE APPROVED
APPLICANT INFORMATION
NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
RESIDENTIAL MAILING ADDRESS
CITY
STATE
ZIP CODE
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CELL PHONE NUMBER WITH AREA CODE
RESPONSIBLE PARTY FOR COMPANY
SOCIAL SECURITY NUMBER*
PREVIOUS MO PERMIT NUMBER (IF APPLICABLE)
Yes
No
BUSINESS INFORMATION
NAME
TELEPHONE NUMBER WITH AREA CODE
BUSINESS MAILING ADDRESS
CITY
STATE
ZIP
PHYSICAL ADDRESS (IF DIFFERENT THAN MAILING)
CITY
STATE
ZIP
COUNTY
FAX NUMBER WITH AREA CODE
BUSINESS EMAIL
FEE STRUCTURE PER PERMIT (FOR WATER WELL, MONITORING WELL, HEAT PUMP AND PUMP) – FEES ARE BASED ON
MONTH APPLICATION IS RECEIVED. ALL PERMITS WILL RENEW ANNUALLY OCTOBER 1
January
$80
March
$60
May
$40
July
$20
September
$10
November
$90
February
$70
April
$50
June
$30
August
$15
October
$100
December
$85
*Applicants are required by state and federal law** to include their Social Security number on this application. The number allows the
department to distinguish between persons who have the same or similar names. The department will not disclose any Social Security
numbers, consistent with Section 610.035, RSMo. The department cannot allow applicants to take the exam or become permitted
without a Social Security number.
**Section 454.403, RSMo, of the Child Support Enforcement Law and Section 317 of the Federal Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, Public Law No. 104-193.
I certify that all information provided in this application is true. I understand that misstatements of facts may result in the forfeiture of my
permit, issued in accordance with Sections 256.600 – 256.640, RSMo. By accepting this permit, I agree to adhere to the Missouri
Water Well Driller’s Act, Sections 256.600 – 256.640, RSMo, and the Missouri Well Construction Rules, 10 CSR 23.
APPLICANT SIGNATURE
IS THIS APPLICATION FOR AN APPRENTICESHIP
DATE
Yes*
No
*If yes, a responsible party signature is required.
BY SIGNING FOR THE ABOVE APPRENTICE, YOU ARE AGREEING TO BE RESPONSIBLE FOR THE APPRENTICESHIP AND
THE APPRENTICE’S WORK
RESPONSIBLE PARTY SIGNATURE
PERMIT NUMBER
DATE
MO 780-1731 (01-18)
SEND COMPLETED FORM ALONG WITH PERMIT FEE(S) TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL
SURVEY, WELL INSTALLATION SECTION, PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2165 FAX: 573-368-2317 EMAIL:
welldrillers@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
MISSOURI GEOLOGICAL SURVEY
NON-RESTRICTED RESTRICTED RESTRICTIONS
CONTRACTOR AND APPRENTICE PERMIT
WATER WELL
TEST HOLE ONLY
PUMP
TEST HOLE ALSO
APPLICATION
MONITORING WELL
PROBATION
HEAT PUMP
PERMIT NUMBER
CHECK NO.
NOTE: THE CONTRACTOR AND APPRENTICE TESTING
APPLICATION AND EXAM MUST BE COMPLETED PRIOR
TEST SCORES
TEST DATE
TEST ID
TO SUBMISSION OF THIS FORM
GEN
/
DATE RECEIVED
DATE APPROVED
APPLICANT INFORMATION
NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
RESIDENTIAL MAILING ADDRESS
CITY
STATE
ZIP CODE
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CELL PHONE NUMBER WITH AREA CODE
RESPONSIBLE PARTY FOR COMPANY
SOCIAL SECURITY NUMBER*
PREVIOUS MO PERMIT NUMBER (IF APPLICABLE)
Yes
No
BUSINESS INFORMATION
NAME
TELEPHONE NUMBER WITH AREA CODE
BUSINESS MAILING ADDRESS
CITY
STATE
ZIP
PHYSICAL ADDRESS (IF DIFFERENT THAN MAILING)
CITY
STATE
ZIP
COUNTY
FAX NUMBER WITH AREA CODE
BUSINESS EMAIL
FEE STRUCTURE PER PERMIT (FOR WATER WELL, MONITORING WELL, HEAT PUMP AND PUMP) – FEES ARE BASED ON
MONTH APPLICATION IS RECEIVED. ALL PERMITS WILL RENEW ANNUALLY OCTOBER 1
January
$80
March
$60
May
$40
July
$20
September
$10
November
$90
February
$70
April
$50
June
$30
August
$15
October
$100
December
$85
*Applicants are required by state and federal law** to include their Social Security number on this application. The number allows the
department to distinguish between persons who have the same or similar names. The department will not disclose any Social Security
numbers, consistent with Section 610.035, RSMo. The department cannot allow applicants to take the exam or become permitted
without a Social Security number.
**Section 454.403, RSMo, of the Child Support Enforcement Law and Section 317 of the Federal Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, Public Law No. 104-193.
I certify that all information provided in this application is true. I understand that misstatements of facts may result in the forfeiture of my
permit, issued in accordance with Sections 256.600 – 256.640, RSMo. By accepting this permit, I agree to adhere to the Missouri
Water Well Driller’s Act, Sections 256.600 – 256.640, RSMo, and the Missouri Well Construction Rules, 10 CSR 23.
APPLICANT SIGNATURE
IS THIS APPLICATION FOR AN APPRENTICESHIP
DATE
Yes*
No
*If yes, a responsible party signature is required.
BY SIGNING FOR THE ABOVE APPRENTICE, YOU ARE AGREEING TO BE RESPONSIBLE FOR THE APPRENTICESHIP AND
THE APPRENTICE’S WORK
RESPONSIBLE PARTY SIGNATURE
PERMIT NUMBER
DATE
MO 780-1731 (01-18)
SEND COMPLETED FORM ALONG WITH PERMIT FEE(S) TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL
SURVEY, WELL INSTALLATION SECTION, PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2165 FAX: 573-368-2317 EMAIL:
welldrillers@dnr.mo.gov