(Please type or print legibly)
1. Applicant Name: _______________________________________________________________
a. Mailing Address: ________________________________________________________
b. City, State, Zip: ________________________________________________________
c. Phone # / Fax #: ________________________________________________________
d. Email address: ________________________________________________________
e. First-time applicant: [ ] Yes [ ] No If No, Permit #______________________
2. Physical location of burn (Please provide one of the following)
Address: _______________________________________________________________
City: ____________________ County: ____________________ Zip: __________
Parcel Number: ________________________________________________________________
Township: _______________ Range: ________________ Section: ________________
Latitude/Longitude, Elevation: __________________________________________________
3. Description of burning location: [ ] Residential [ ] Agricultural [ ] Construction
[ ] Range Land [ ] Other (state:__________________)
[“Agricultural Burning” means burning vegetative materials related to producing and harvesting crops
and raising animals for the purpose of marketing for profit or a providing a livelihood, but does not include
burning of household waste or prohibited materials. A person may conduct agricultural burns in fields,
piles, ditch banks, fence rows, or canal laterals for purposes such as weed control, waste disposal, disease
and pest prevention, or site preparation.]
4. Type of material to be burned: [ ] Brush [ ] Grass [ ] Crop [ ] Weeds
[ ] Untreated Wood/Lumber
[ ] Cut tree(s), please state diameter__________Inches
[ ] Other, please explain______________________________
5. Estimated quantity of material to
be burned: [ ] Number of cubic yards __________________, or
[ ] Number of piles _______________________, or
[ ] Number of acres ________________________
6. Material to be burned shall be: [ ] Piled [ ] Collected in a pit
[ ] Ignited in place (Agricultural Burning Only)
[ ] Ditch burning [ ] Placed in an approved waste burner
[“Approved waste burner’” means an incinerator constructed of fire resistant material with a cover or
screen that is closed when in use, and has openings in the sides or top no greater than one inch in
7. Anticipated duration per burn in hours: _______________________________________________
8. Estimated number of days to burn all material: ________________________________________
9. Purpose(s) of burning: [ ] Weed abatement [ ] Fire prevention
[ ] Range improvement [ ] Crop removal
[ ] Others (Please explain) ___________________________________
10. What types of actions will be taken to minimize fire emissions including any Emission Reduction
Techniques (ERTs)? ERTs include, but are not limited to:
Minimize the material to be burned;
Prevent fire from spreading by lining the area where open burn is conducted and
application of fire retardant foam, or water;
Allow the material to dry before burning;
Minimize soil content in slash piles by constructing piles under dry soil conditions or by
using hand piling methods;
Burn in piles;
Use a back fire when grass is burned; (back firing is burning in opposite direction of the
Extinguish the smoldering burns;
Burn before litter falls;
Burn prior to precipitation;
Other (Please provide a description of the techniques you will be using to minimize the
emissions from your open burning activities): _________________________________
11. Burn area must be at least 50 feet from your home, our neighbors, and business.
a. What is the distance from the burn location to your residence? ________ feet
b. What is the distance from the burn location to your neighbors? ________ feet
c. What is the distance from the burn location to nearby businesses? _______ feet
(Please note, permit can not be issued if the distance is less than 50 feet)
12. Please provide a either a hand drawn map or Google/Bing/Mapquest/county assessor or parcel
map of the burn location, depicting the burn area, traveled roads, airports, and the distance from
nearby buildings/structures (including fuel tanks, gas lines) that are under your ownership or
another persons ownership. In your map, please use a line to note the distances between the burn
location and buildings/structures in feet. Please see the example:
13. Fire controls available (e.g., water hose, shovels, dirt): __________________________________
14. Nearest Fire Department: __________________________________________________________
15. Fire department phone #: __________________________________________________________
16. Please contact your local fire department before burning. You may be required to obtain a permit
from them, before being allowed to burn.
I certify that I have knowledge of the facts herein set forth, that the same are true, accurate and complete to
the best of my knowledge and belief. I further state that I will assume responsibility for conducting open
burning in accordance with the Arizona Administrative Code, Title 18, Chapter 2 and any open burning
permit issued thereof.
Signature: __________________________________________________________ Date: _____________
Typed or printed name of signer: ___________________________________________________________
Mailing Addresses:
If the burning is to be conducted in Apache,
Coconino, Gila, La Paz, Mohave, Navajo,
Yavapai or Yuma Counties please mail/fax to:
Arizona Department of
Environmental Quality
ATTN: Air Quality Division
1110 W. Washington Street
Phoenix, AZ 85007
Phone #: (602) 771-2338
Fax #: (602) 771-2299
If the burning is to be conducted in Cochise,
Greenlee, Graham, or Santa Cruz Counties
please mail/fax to:
Arizona Department of
Environmental Quality
Southern Regional Office
400 W. Congress, Suite 433
Tucson, AZ 85701
Phone #: (520) 628-6733
Fax #: (520) 628-6745
My house
Burn area
300 feet
300 feet
Road Name
75 feet
Road Name
50 feet