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Fail Date Date Done By Comments CD CD Co CD (A 0 0 0 0 ............ 0 rD -_-_----_- as CD 0 f ''"` ti EXPIRATION DATE: -�'�<lC= MASON COUNTY BURN PERMIT APPLICATION 615 W ALDER STREET• SHELTON WA 98584 SHELTON 360.427.9670•BELFAIR 360.275.4467•ELMA 360.482.5269 APPLIC4kNT INFORMATION: CONTRACTOR INFORMATION: ' .Owner_ ,wyIm Owner f')c.ri1d i1,<� Mailmi Address Mailing Address City State W A- Zip Y�J`Z�f City State Zip Phone Cell Phone Cti+a Phone Other Phone Lien/Title Holdcr_j,vy\�),-,{'/--i i-�� \30,0 K Contractor Reg.# Exp. E-mail address/t,(v)°G. h of Z$Irk 1,WrA E-mail address Drivers Lic.#L et n+n.�.M 1$ 3 DOB Z,� �Z- Drivers Lic.# D.O.B. TAX PARCEL NUMBER Lf:A -Oc�'C'6)(� (12 digit number) Fire District SITE ADDRESS(please include street name,number&city 3, i . 1- /c+)<e Cl,f�S 1ir+e 1Zc� Directions to the site 1 w-c+ 3 1 ,r) c, e+ wc. Tr+i V1 (�,'c c✓ CA Moo" 4Lin '1t a/Kc G-1,riSt�n �c Parcel within 200'o£ Saltwater❑ Lake❑ River/Creek❑ Pond❑ Wetland❑ Seasonal Runoff❑ Stream❑ Slopes or Bluffs> 15% Yes/ O i Will member be cut and sold in parcel preparation? e Does Site require FPA or 6 vr_Moratorium:Yes Is site being converted or renlanted: Ye, o BURNING IS AUTHORIZED SUBJECT TO THE FOLLOWING CONDITIONS: • Valid permit MUST be onsite while burning.If permit is not on site during burning the fire will be extinguished at your cost. • 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 burning 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 burn 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 15t'and Oct. 151.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 • 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 burn 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 individual 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 burn 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 OWNER/CONTRACTOR: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 of the firp 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 ts2u !�fenlorcement action. _ X Date � Z f SI ATURE-MUST BE SIGNED BY PROPERTY OWNER Lt - Burn Per # J1 C PARCEL AND SITE INFORMATION: Parcel within 200'of: Saltwater❑ Lake❑ River/Creek/Stream❑ Pond❑ Wetlands❑ Seasonal Runoff❑ Yes/None Slopes or Bluffs> 15% Yes/ Will timber be cut and sold in parcel preparation?Yes/No Does Site require FPA or 6 yr. Moratorium: Yes/No Is site being converted or replanted: Yes/No Is site located in an Urban Growth Area(UGA)?: Yes/No Unknown [Burning is currently NOT allowed inside UGAJ Zoning. . Summarize proposed land clearing items to be burned: SITE PLAN (to be verified and approved by Planner) In the space provided below, please draw a top-view site plan of the parcel and notate locations of the following items with distances to/from"Burn Pile": o Burn Pile and Feeder Piles o Any existing buildings/structures (ie: Residence, Garage, Storage shed, Driveway, etc.) o Existing standing timber o Any "Critical Areas" such as Steep Slopes, Lake, River/Creek, Wetlands, Seasonal Runoff, Streams, etc - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 GO ewc.1 OWNER/CONTRACTOR: 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 of 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 result of an enforcement action. X SIGNATURE-MUST BE SIGNED BY PROPERTY OWNER Date Signed Mason County Map Output Page Page 1 of 1 Mason County Map LEGEND NE TWIN LAKES RD L NFL I�,��A " W � � tr ,cAr i:4Mo cnHsriae,_ NE 3 Stipp d NE LAKE CNRISnNE RD DISCLAIMER AND LIMITATION OF LIABILITY: The data used to make this map have been tested for accuracy.and even effort has been made to ensure that 1 these data are limely,accurate and reliable.However, '> Mason County makes no guarantee or warrant,to its accuracy as to labeling,dimensions,or placement or Lskv{gYroterA ,;;,� location of any map features contained herein.The 1 boundaries depicted bti these data are appro—ale,and are not necessanh accurate to curve,m&or engineering standards.and are intended for informational purposes A m nly Mason n oars dO the.does not assume an%legal habiln, o ✓may. Ays Qqj P s a manner not untended by Mason Counn.In no event shall Mason CoumN be liable for direct,indirect.incidental. -4 2 consequential,special or tort damages of ans kind. including,but lot Immed to,loss of anticipated piolits or 2 benefits arising from use of or reliance on the information contained herein A& a 3 z ©2009 Mason Countv GIS 100 W.Public Works Dr �✓ z B d 0 Shelton,WA 98584 http://mapmason.co.mason.wa.us/servlet/com.esri.esrimap.Esrimap?ServiceName=amason_... 3/3/2017