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DATE OF APPLICATION <br />BURN DATE(S) REQUESTED <br /> <br />Minnesota Pollution Control Agency <br /> 612-296-7300 <br /> <br />LICATION FOR PERMIT FOR OPEN BURNING <br /> <br />NAME TEL. NO. <br /> <br />REPRESENTING <br />ADDRESS <br /> <br /> (Street, City and Zip Code) <br />request permission to conduct open burning at <br /> <br />(H) <br /> <br />(0) <br /> <br />I <br />I <br />I <br /> <br />in the County of Sec. Twsp. Range <br /> <br />Distance in feet from nearest occupied residence other than applicant's <br /> · For the purpose of <br /> <br />This application for open burning can be accomplished in accordance with <br />the conditions listed on the reverse side. The recipient of the permit <br />shall comply with all other state and local laws regarding open burning <br />including obtaining the required permits. <br /> <br />(Signature of Applicant) <br /> <br />LOCAL APPROVAL FOR OPEN BURNING <br /> <br />This permit application is submitted with the knowledge and recommenda- <br />tion of a local fire authority or local governmental authority having <br />jurisdiction where the burning is to be conducted. Any burning con- <br />ducted under this permit request would be in accordance with MPCA <br />regulations and would not violate local ordinances. Applicant meets <br />600 foot minimum distance requirement from occupied residences other <br />than those located on the property upon which the burning is conducted. <br /> <br />NAME TITLE TEL. NO~ <br /> <br />ADDRESS <br /> <br />INSPECTED BY <br /> <br />PF~-00225-0~ <br /> <br />(Street. City and Zip Code) <br />DATE OF INSPECTION <br /> <br /> Phone: <br />1935 West County Road B2, Roseville, Minnesota 55113-2785 <br /> Regional Offices · Duluth,~Brainerd/Detroit Lakes/MarshalFRochester <br /> Equal Opportunity Employer <br /> <br /> <br />