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Minnesota Pollution Control Agency <br /> 520 La;ayette Road, Sain: Pa,al, Minnesota 55155 <br /> Telephone (612) 296-6300 <br /> <br />M ~ NN 7~S.0'[^ <br /> <br />DATE OF APPLICATION <br /> <br />BURN DATES REQUESTED <br /> <br />APPLICATION FOR PERMIT FOR OPEN BURNING <br /> <br />NAME <br /> (Print) <br />REPRESENTING <br /> <br />ADDRESS <br /> (Street, City and Zip Code) <br /> <br />TELEPHONE NO. (H) <br /> <br />request permission to conduct open burning at (specify street, city and county <br /> <br />Actual distance in feet from the nearest occupied residence other than <br />applicant's . Provide in detail type and amount of material <br />to be burned and why burning is necessary: <br /> <br />LOCAL APPROVAL FOR OPEN BURNING <br /> <br />This permit application is submitted with the knowledge and recommendation of <br />local fire authority of local gcvernmental authority having jurisdiction where <br />the burning is to be conducted. Amy burning conducted under this permit <br />request would be in accordance with MPCA regulations and would not violate <br />local ordinances. Applicant meets 600 foot minimum distance requirement from <br />occupied residences other than those located on the property upon which the <br />burning is conducted. <br /> <br />NAMr <br /> <br />ADDRESS TEL. NO. <br /> <br />(Street, City and Zip Code) <br /> <br />![{SPECTED BY <br /> <br />(Print) <br /> <br />DATE OF INSPECTION <br /> <br />SIGNATURE OF INSPECTOR <br /> <br />PQ-00225-01 (Revised February 1989) <br /> Regiona! Offices: Duluth · Brainerd · Detro~ Lakes · Marshall. Rochester <br /> Equal Opportunity Employer Printed on Recycled Pap~l4 <br /> <br /> <br />