LOCAL OPEN BURNING OFFICIAL: Permit Number:
Application and Permit for
“Open Burning for the Eradication or Control of Town of Southbury
Insect Infestations or Disease” on
Non- State-Owned Property
APPLICANT INFORMATION
Applicant Name:
Applicant Signature:
Applicant’s Address:
Home Phone:
Work Phone:
Applicant’s Email Address: Cell Phone:
Street Address of the proposed burn:
Date(s) and Time(s) of proposed burn:
Description and purpose of the proposed activity including the strategy to be undertaken:
Documentation indicating that insect infestation or disease has been identified by someone with expertise in the
Field:
Written Documentation of Infestation or Disease Provided
Justification that open burning is the preferred management practice:
Written Documentation Provided
Methods and equipment immediately available to control and extinguish the burn:
Documented Proof of Ownership of the property on which the open burning is proposed to occur. If the Applicant
is not the owner of the property, then Documented Proof of Ownership of the property on which the open burning is
proposed to occur and Authorization from the Property Owner to conduct the proposed burn:
Written Documentation of Ownership
Written Documentation of Authorization
Notification to adjacent property owners prior to proposed burning:
Written Documentation Provided
Any other information as required by the Open Burn Official:
Written Documentation Provided
Attached Sketch Map Showing:
Geographic North
Property line boundaries; Proposed burn location; Distance to the nearest grasslands or woodlands
Nearest public roads, structures and occupied dwellings and distances (i.e. potential recipients that could be
impacted by the burn, smoke, flying embers, brands or radiant heat; potential runoff into catch basins, streams,
rivers, and water bodies)
Other flammable or combustible materials including liquid and/or gaseous storage above or below ground on site or
upon abutting or adjacent properties
Any hazards, i.e. overhead utilities
Other
END OF APPLICATION
Over
2013
PERMIT CONDITIONS
1. This is a valid permit only when signed by the Local Open Burning Official.
2. The permit does not relieve the permittee of any legal liability which may be incurred as a result of the fire.
3. Failure to adhere to the conditions of the permit may result in penalties and/or other enforcement actions.
THIS PERMIT IS NOT
VALID UNDER ANY
OF THE FOLLOWING
CONDITIONS:
When national or state ambient air quality standards may be exceeded.
Where a hazardous health condition might be created.
When the Air Quality Index (AQI) is predicted to be 75 or higher anywhere in the State as
indicated in the Table entitled “Predicted Daily AQI Maximums for Month/Day/Year” as
found at www.ct.gov/deep/aqi
When the Forest Fire Danger Level is high, very high, or extreme, as found at
www.ct.gov/deep/forestfiredanger
When there is an advisory from the State of Connecticut’s Department of Energy and
Environmental Protection of any air pollution episode.
GENERAL CONDITIONS:
APPLICABLE
TO ALL
PERMITS
1. Open burning is limited to the activities as approved by the local Open Burning Official.
2. Burning must cease if so directed by any member of the Town Fire Marshal's Office, any
Peace Officer, any Officer of the Fire Department, any designated municipal official
responsible for enforcing the open burning laws and ordinances or any Official of the
State of Connecticut’s Department of Energy and Environmental Protection.
3. During the burn all reasonable measures to assure complete combustion and reduce
excessive smoke are to be taken.
4. At the completion of the burn period, all embers and coals shall be extinguished so as to
prevent excessive smoke and fugitive ash emissions.
5. All reasonable safety precautions shall be taken and fire suppression/control equipment
shall be immediately available.
6. This permit must be immediately available on site during the burn.
7. Burning may only be conducted between the hours of 10:00 A.M. and 5:00 P.M. on a
sunny or partly sunny day with the wind speed between five and fifteen miles per hour.
*There may be exceptions. This condition may change based on best management
practices for the activity proposed.
8. Burning shall not create a nuisance to nearby properties.
THIS SECTION TO BE COMPLETED BY THE LOCAL OPEN BURNING OFFICIAL
SPECIAL
CONDITIONS:
APPLICABLE IF
CHECKED
Burning may be initiated only in the presence of the Open Burning Official.
A fire crew and appropriate apparatus must be stationed at the burning site prior to
ignition.
Burning may not take place when the wind is from the _____________ direction.
Final verbal approval must also be obtained on the day of and prior to the burning by
calling
203-262-0637.
Burning must be conducted on: ____ day(s) between the following dates:
From: ____/____/____ to ____/____/____
Violation of the terms and conditions of this permit may cause the forfeiture of your ability
to qualify for a permit in the future.
Other conditions:
In evaluating this application, did the Open Burning Official find it necessary to consult with The Connecticut
Agricultural Experiment Station?
Yes No
This permit is GRANTED.
This permit is NOT GRANTED for the following reasons:
Local Open Burning Official Signature:
Town:
Southbury
Date:
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