2. Name (First and Last)*
3. Phone Number*
5. Mailing Address*
7. City*
8. State*
9. Zip Code*
11. Email Address*
13. Driver's Licence/State ID Number*
14. State*
15. Expiration Date*
17. Requested location of Bonfire*

    1. Eastside of Beach Park Pier
    2. Westside of Beach Park Pier
    3. Point Park
18. Requested Date and Time of Bonfire*
    Requested Date and Time of Bonfire

    Requested Date and Time of Bonfire
20. Agreement*

    1. By checking this box, I understand all reservations are not guaranteed until I have received confirmation from an office staff member. Applications are reviewed during normal business hours.
22. *A representative of the Pascagoula Fire Department will stop by on the date of the Bonfire to verify compliance and answer any questions.*
24. In order that we may be in compliance with Air Emission Regulations for the prevention, abatement and control of air contaminants, as published by the Mississippi D.E.Q. Office of Pollution Control, this permit allows ONLY the burning of natural vegetation i.e. firewood. The burning of other materials such as lumber, pallets and the like subjects you to fines from the city of $1,000 or 90 days in jail or both. (See Code of Ordinances City of Pascagoula Mississippi Sec. 1-8) In addition, you may be reported to the DEQ and face fines up to $25,000.
    
    All fires shall be extinguished with water only. Smothering, as with sand is prohibited. Permit expires at midnight of the date of Bonfire.
    
    All burning shall be completed by midnight of the permit expiration. All materials burned and unburned shall be removed at permit expiration. Any and all material not removed shall be considered a violation of the City Code of Ordinances Sec. 70-8 and subject permit holder to stated fines. This permit is not transferable, can be revoked if provisions contained herein are not complied with. The holder of this permit does herby agree that in the event of damage of person or property, HE/SHE ACCEPTS FULL RESPONSIBILITY AND LIABILITY.
26. Electronic Signature *

    By checking the "I agree" box below, you agree and acknowledge that 1) all of the information on this form is accurate, 2) you understand and agree to the rules set forth by MDEQ.

    1. I agree.
28. Electronic Signature*
29. Submit Date*
    Submit Date
31. You will be contacted via the email provided regarding status.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field