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. Address of burn if different than above
19. Agreement*

    1. By checking this box, I understand my application is not approved until I have received confirmation from an office staff member. Applications are reviewed during normal business hours.
21. 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 ONLY permits:
    7D. Fires set for recreational purposes (Weiner Roast, Pep rallies, Etc.)
    7E. Fires set for backyard reductions of leaves on the premises on which they fall
    7F. Fires used to dispose of natural vegetative waste resulting from storm damage.
    
    1. This permit is not transferable.
    2. Shall be revoked if provisions contained herein are not complied with.
    3. Burning in the street, on the sidewalks and neutral grounds is strictly prohibited.
    4. Leaf piles are to be kept to a minimum.
    5. Fires are not to be left unattended.
    6. Facilities and/or access to a water supply to control fire shall be maintained on the scene.
    7. The holder of this permit does hereby agree that in the event of damage of property of other, HE ACCEPTS FULL RESPONSIBLILTY AND IS LIABLE FOR ALL CHARGES RESULTING FROM A SUIT.
    8. Upon complaint by any citizen that a smoke or odor nuisance is created, this permit shall be revoked without written notice.
    9. Burn only from 8:00 A.M. to Dark / Dusk
    10. Burning of Tires, Plastics, Oil, lumber or Shingles is strictly prohibited.
    
    This permit allows ONLY the burning of natural vegetation. The burning of prohibited materials 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 per day per occurrence.
    
    An approved burn permit will be valid for 30 days from date of approval.
23. 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.
25. Electronic Signature*
26. Submit Date*
    Submit Date
28. You will be contacted via the email provided regarding status.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field