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Y d N a) = a� U m > m ._ N Z mrn > > m 0 L m N N 0 ui J 3 N CoWz n'OC-' n01 N C O Co ID L >o a (D0 mom zmC � m OOooaJ C O) C z 0 O m U d N d m i .sue EXPIRATION DATE: S ZZ b BRN2016-DOD MASON COUNTY BURN PERMIT APPLICATION 615 W ALDER STREET• SHELTON WA 98594 SHELTON 360.427.9670 •BELFAIR 360.275.4467 •ELMA 360A82.5269 APPLIC,A,,NT INFORM CONTRACTOR INFORMATION: Owner �w � a d USdv� Owner Mailing Address Q b 2, b6 .,, .- e_._ Mailing Address City aStateyal {L Ip $SD City State Zip Phone .2; - Z Cell Phone 5(e m 2`+9 - izY Phone Other Phone Lien/Title Holder tZ, 10 Contractor Reg.# Exp._/ / E-mail address Doj30A err^^ K 'C' -mail address Drivers Lic.# Drivers Lic.# D.O.B. TAX PARCEL NUMBER (12 diA number) Fire District SITE ADDRESS(please m ude street name,n ber&city '!ii 1 y S t2 �e $�o_ Directions to the site f, o� 1 u 3 Parcel within 200'of: Saltwater o Lake❑ River/Creek o Pond❑ Wetland❑ Seaso Runoff❑ Stream❑ Slopes or Bluffs> 15% Yes/10 Wi I timber be cut and sold in parcel preparation? /No Does Site require FPA or 6vr. Moratorium: o is site beine converted or renlanted:Y o BURNING IS AUTHORIZED SUBJECT TO THE FOLLOWING CONDITIONS: Valid permit MUST be onsite while burning If Mrmit is not on site during burning the fire will be extinguished at your cost. i• The following materials are prohibited and must not be burned: garbage, dead animals, asphalt,petroleum products, paints, rubber products, plastics, paper, cardboard, treated wood, construction/demolition debris, metal or any substance (other than natural vegetation)that releases toxic emissions,dense smoke,or obnoxious odors when burned. • . All materials must originate from the property on which the buming is to occur. • The fire must not create a nuisance from smoke,obscure visibility on public roads and highways,or endanger life and property. • Maximum pile size is twenty(20)feet in diameter,a minimum ten(10)feet firebreak must be constructed around each pile. Each pile must be at least one hundred(100)feet from any structure and at lease fifty(50)feet from standing timber. ✓ Do not bum if wind is blowing more than seven(7)miles per hour. DO NOT BURN IF WIND BLOWING FROM • A responsible adult and equipment shall be on site and in attendance at the fire while burning.Must provide 24 hour fire watch. •- On Site Water is required for permits between April 15'and Oct. 156'.A pump truck or trailer with 300 gallons of water loaded and 200 ft of hose.(The pump must be capable of pumping 20 gallons per minute through a one inch(diameter)50 foot section of hose.) • Provide EXCAVATOR/DOZER(with fire extinguisher)on site with qualified operator. •- Fire must be completely extinguished within three(3)days after ignition •. Fan required. • Upon completion of above conditions,applicant must have inspection&approval before ignition.Call (360)427-9670,ext.262 t APPLICANT'S MUST CALL 360.426.4441,EACH DAY TO REPORT BURNING ACTIVITY. `• APPLICANTS MUST CALL 360 539 7610(ORCCA)EACH DAY TO REPORT/REQUEST ANY AIR QUALITY ISSUES ASSOCIATED WITH BURNING. ************IF BURNING WITHOUT CALLING IN,THE FIRE WILL BE EXTINGUISHED AT OWNERS EXPENSE AND POSSIBLE SUSPENTION OF PERMIT.*************** • After the bum is complete make sure the fire has not burned into the earth by checking the fire location for hot spots. • It is advisable to pump the entire content of the water tank onto the bum site to assure the fire is completely extinguished. The permitted individuQ is responsible for any rekindling on the fire/bum site. • A BURN BAN when implemented by Fire Marshal will take effect as noted and all permits become null and void.After a bum ban has been implemented,all fires must be extinguished immediately. • Permit includes two(2)inspections maximum,additional inspections will require a re-inspection fee.(at current rate) • Access must be passable with 2 wheel drive vehicle OWNEWCONTRACTOR: Acknowledges submission of inaccurate information may result in a stop work order or permit revocation. Acknowledgement of such is by signature below.The owner represents that the information provided is accurate and grants employees of Mason County&local fire authorities access to the above described property and structure for review and inspection.The person in charge f the fire will be liable for the cost of suppression if the fire gets out of control or if becomes necessary to extinguish the fire as the of an enforcement action. ?C Date SIG UR -MUST BE SIGNED BY PROPERTY OWNER