Form OLWR-PI-2 "Pump Installer License Application Form" - Mississippi

What Is Form OLWR-PI-2?

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

Form Details:

  • Released on April 1, 2011;
  • The latest edition provided by the Mississippi Department of Environmental Quality;
  • 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 OLWR-PI-2 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Environmental Quality.

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Download Form OLWR-PI-2 "Pump Installer License Application Form" - Mississippi

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Mississippi Department of Environmental Quality
Office of Land and Water Resources
P.O. Box 2309
Jackson, MS 39225
PUMP INSTALLER LICENSE
Application Form
OLWR-PI-2(4/11)
1. APPLICANT:
Name ______________________________ Date of Birth ____________
Address ___________________________________________________
City _________________________ State _____ Zip Code___________
Telephone Number ________________
2. BUSINESS:
Company Name ______________________________________________
Address ____________________________________________________
City ________________________ State ______ Zip code __________
Telephone Number ________________
3. EXPERIENCE RECORD:
(a) Have you ever been denied a Pump Installer’s License or had such license
revoked, cancelled, or suspended by any state? ____yes ___no
If you checked yes, provide the details in Block 5 ADDITIONAL
INFORMATION / COMMENTS including the date and reason the action was taken, and the
state in which the action was taken.
(b) How many years have you been installing and servicing water well pumps? _____
(c) How many pumps have you installed in the past three (3) years?_____
(d) Of the number included in 3.(c), how many were for: Home wells _________
Industrial wells ___ Public Water Supply wells ______ Irrigation wells _______
(e) Are you a licensed to install pumps in another state?____ If so, What state?____
(Attach a copy of your current license from the state named above to this application.)
(f)
Contractors License Number (Certificate of Responsibility)
Applicants for water well contractors, pump installers and geothermal drillers licensing must
provide their contractor's license number from the Mississippi Board of Contractors (attach a
copy of your current contractors license to this application).
4. REFERENCES:
(a) Provide the names, license numbers, licensing state, and contact information for
at least one (1) but not more than three (3) licensed drillers who have either supervised your work
and/or have first hand knowledge of your qualifications and experience in the field for which you
are seeking a license.
Name _____________________________Lic. No._______Licensing State____
Address___________________________Telephone No.___________________
City _________________________________ State____ Zip Code__________
Name _____________________________Lic. No._______Licensing State____
Address___________________________Telephone No.___________________
1
Mississippi Department of Environmental Quality
Office of Land and Water Resources
P.O. Box 2309
Jackson, MS 39225
PUMP INSTALLER LICENSE
Application Form
OLWR-PI-2(4/11)
1. APPLICANT:
Name ______________________________ Date of Birth ____________
Address ___________________________________________________
City _________________________ State _____ Zip Code___________
Telephone Number ________________
2. BUSINESS:
Company Name ______________________________________________
Address ____________________________________________________
City ________________________ State ______ Zip code __________
Telephone Number ________________
3. EXPERIENCE RECORD:
(a) Have you ever been denied a Pump Installer’s License or had such license
revoked, cancelled, or suspended by any state? ____yes ___no
If you checked yes, provide the details in Block 5 ADDITIONAL
INFORMATION / COMMENTS including the date and reason the action was taken, and the
state in which the action was taken.
(b) How many years have you been installing and servicing water well pumps? _____
(c) How many pumps have you installed in the past three (3) years?_____
(d) Of the number included in 3.(c), how many were for: Home wells _________
Industrial wells ___ Public Water Supply wells ______ Irrigation wells _______
(e) Are you a licensed to install pumps in another state?____ If so, What state?____
(Attach a copy of your current license from the state named above to this application.)
(f)
Contractors License Number (Certificate of Responsibility)
Applicants for water well contractors, pump installers and geothermal drillers licensing must
provide their contractor's license number from the Mississippi Board of Contractors (attach a
copy of your current contractors license to this application).
4. REFERENCES:
(a) Provide the names, license numbers, licensing state, and contact information for
at least one (1) but not more than three (3) licensed drillers who have either supervised your work
and/or have first hand knowledge of your qualifications and experience in the field for which you
are seeking a license.
Name _____________________________Lic. No._______Licensing State____
Address___________________________Telephone No.___________________
City _________________________________ State____ Zip Code__________
Name _____________________________Lic. No._______Licensing State____
Address___________________________Telephone No.___________________
1
City _________________________________ State____ Zip Code__________
Name _____________________________Lic. No._______Licensing State____
Address___________________________Telephone No.___________________
City _________________________________ State____ Zip Code__________
(b) Provide the names and contact information of two (2) clients, not related to
you, for whom you have recently installed a water well pump.
Name _________________________________ Telephone No.______________
Address__________________________________________________________
City _________________________________ State____ Zip Code__________
Name _________________________________ Telephone No.______________
Address__________________________________________________________
City _________________________________ State____ Zip Code__________
5. ADDITIONAL INFORMATION / COMMENTS:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
7. I hereby certify, under penalty of revocation of any license issued pursuant to this
application, that I have the requisite three (3) years experience required to apply and that the information I have
provided in this application is true and correct, to the best of my knowledge. I further grant my references
authority to provide information regarding my experience and qualifications related to the license I am seeking to
the Mississippi Department of Environmental Quality in support of this application.
____________________________________________
Signature of Applicant
NOTARY:
STATE OF __________________, COUNTY OF ________________________
THIS DAY, ____________________________ personally came and appeared before
the undersigned authority in and for the aforesaid jurisdiction.
SWORN to and subscribed before me on this the ______ day of ___________, 20____.
My Commission expires: __________________ ___________________________
NOTARY PUBLIC
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