"Land Treatment Application" - Arizona

Land Treatment Application is a legal document that was released by the Arizona State Land Department - a government authority operating within Arizona.

Form Details:

  • Released on December 1, 2009;
  • The latest edition currently provided by the Arizona State Land Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arizona State Land Department.

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LAND TREATMENT
INFORMATION SHEET
To avoid having your application rejected, please READ prior to submitting your application.
1.
FILING INSTRUCTIONS:
A.
Filing fee: Non-refundable $150.00 filing fee.
B.
Submit ONE APPLICATION PER PROJECT.
C.
Complete all questions and SIGN the application on Page 3.
2.
SIGNATURE(S):
The application MUST BE SIGNED BY THE LESSEE(S)/PERMITTEE(S) OF RECORD. If anyone
other than the lessee(s)/permittee(s) signs this application, a notarized written authorization (Power of
Attorney) must accompany the application. An additional $50.00 filing fee is required when filing a
Power of Attorney.
3.
ACREAGE LIMITATION:
Land Treatment Applications shall be limited to the scope of work that can feasibly be completed
within 12 months from the date of approval. Each ground disturbing Land Treatment Application
shall be limited to a maximum of 4,000 treatable acres. Acreage in leave areas (areas not treated due
to slope, cultural resources, depth to bedrock, protected plants or wildlife habitat) is not considered as
treatable. Applicants should discuss proposed land treatments with their Range Resource Area
Manager prior to submitting an application to determine whether the project needs to be divided into
phases. A separate application shall be filed for each phase. Applicants may use Arizona State
Museum (ASM) approved archaeological consultants for archaeological clearances.
These
consultants must prepare a survey Report meeting ASM and ASLD requirements. The applicant
shall submit this report to the ASLD prior to approval of the application.
4.
WRITTEN APPROVAL REQUIRED:
WRITTEN APPROVAL OF THE STATE LAND COMMISSIONER IS REQUIRED BEFORE A
LAND TREATMENT CAN BE COMMENCED.
5.
PROCESSING TIME:
PLAN AHEAD. Expect a minimum of ninety days processing time for this application to be reviewed
by the State Land Department. This application must be reviewed by some or all of the following
agencies: Arizona Game and Fish Department, Arizona State Museum, State Historic Preservation
Office, Arizona Department of Agriculture, and the Forestry Division. These agencies require
between thirty (30) and sixty (60) days to review and respond to the Department.
6104-02/93 (Rev. 12/2009) Land Treatment
LAND TREATMENT
INFORMATION SHEET
To avoid having your application rejected, please READ prior to submitting your application.
1.
FILING INSTRUCTIONS:
A.
Filing fee: Non-refundable $150.00 filing fee.
B.
Submit ONE APPLICATION PER PROJECT.
C.
Complete all questions and SIGN the application on Page 3.
2.
SIGNATURE(S):
The application MUST BE SIGNED BY THE LESSEE(S)/PERMITTEE(S) OF RECORD. If anyone
other than the lessee(s)/permittee(s) signs this application, a notarized written authorization (Power of
Attorney) must accompany the application. An additional $50.00 filing fee is required when filing a
Power of Attorney.
3.
ACREAGE LIMITATION:
Land Treatment Applications shall be limited to the scope of work that can feasibly be completed
within 12 months from the date of approval. Each ground disturbing Land Treatment Application
shall be limited to a maximum of 4,000 treatable acres. Acreage in leave areas (areas not treated due
to slope, cultural resources, depth to bedrock, protected plants or wildlife habitat) is not considered as
treatable. Applicants should discuss proposed land treatments with their Range Resource Area
Manager prior to submitting an application to determine whether the project needs to be divided into
phases. A separate application shall be filed for each phase. Applicants may use Arizona State
Museum (ASM) approved archaeological consultants for archaeological clearances.
These
consultants must prepare a survey Report meeting ASM and ASLD requirements. The applicant
shall submit this report to the ASLD prior to approval of the application.
4.
WRITTEN APPROVAL REQUIRED:
WRITTEN APPROVAL OF THE STATE LAND COMMISSIONER IS REQUIRED BEFORE A
LAND TREATMENT CAN BE COMMENCED.
5.
PROCESSING TIME:
PLAN AHEAD. Expect a minimum of ninety days processing time for this application to be reviewed
by the State Land Department. This application must be reviewed by some or all of the following
agencies: Arizona Game and Fish Department, Arizona State Museum, State Historic Preservation
Office, Arizona Department of Agriculture, and the Forestry Division. These agencies require
between thirty (30) and sixty (60) days to review and respond to the Department.
6104-02/93 (Rev. 12/2009) Land Treatment
6.
OTHER REQUIREMENTS:
Land treatments may impact archaeological sites, threaten wildlife species, protected plants and
natural products with commercial value, such as fuel wood or cactus. The approved Land Treatment
application may include specific conditions which will lessen the impact on these resources. All
conditions incorporated into an approved application MUST be adhered to.
7.
ASSISTANCE:
Contact one of the following Sections for technical assistance, if required.
Agriculture
(602) 542-3500
Commercial
(602) 542-1704
Grazing
(602) 542-4625
Homesite
(602) 542-1704
Title and Contracts
(602) 542-4602
Arizona State Land Department
1616 West Adams
Phoenix, Arizona 85007
6104-02/93 (Rev. 12/2009) Land Treatment
RETURN TO:
ROLODEX # _____________
DEPARTMENTAL USE ONLY
ARIZONA STATE LAND DEPARTMENT
LEASE/PERMIT # ________-_________________
PUBLIC COUNTER
ACCOUNTING
T &C
1616 WEST ADAMS
PHOENIX, ARIZONA 85007
Filing Fee:
$150
Exam: _____________
SUBMIT NON-REFUNDABLE
(28)
App Entry __________
$150 FILING FEE
LAND TREATMENT APPLICATION
COMPLETE ALL QUESTIONS, SIGN AND SUBMIT APPLICATION WITH NON-REFUNDABLE
$150 filing fee.
Applicant hereby makes application and request permission from the Arizona State Land Department for Land
Treatment on State land described below, which is administered in accordance with the statutes of the State of Arizona
and the State Land Department rules.
1. STATE LESSEE OR PERMITTEE:
_____________________________________________________________
Name(s)
_____________________________________________________________
_____________________________________________________________
Mailing Address
_____________________________________________________________
City
State
Zip
_____________________________________________________________
Contact Person
Phone No.
_____________________________________________________________
Email Address (optional)
2. PURPOSE AND TIME OF YEAR:
A. Purpose and description of the Land Treatment:
_______________________________________________________________________________________
_______________________________________________________________________________________
B. Specify the time of year (month) for the Land Treatment:
3
.
LEGAL DESCRIPTION/LOCATION OF PROPOSED LAND TREATMENT:
LOCATION OF LAND TREATMENT
START
COMPLETION
TWN.
RNG.
SEC.
WITHIN SECTION
DATE
DATE
________
________
________
______________________________________
____________
_____________
________
________
________
______________________________________
____________
_____________
________
________
________
______________________________________
____________
_____________
________
________
________
______________________________________
____________
_____________
4. ENVIRONMENTAL PERMITS:
Have you acquired all necessary permits from the Arizona Department of Environmental Quality, Arizona
Department of Agriculture, Corps of Engineers and/or County Health Department?
9
9
Yes
No
1
6104-02/93 (Rev. 12/2009) Land Treatment
5. LAND TREATMENT METHODS:
9
9
A. MECHANICAL:
Yes
No
1. Method:
Pushing
Chaining
Rootplow
Other: ______________________________
2. Type of Machinery: _______________________________________________________________________
9 Yes
9 No
B. CHEMICAL:
Is this a Restricted Chemical? 9 Yes 9 No
1. Name of Chemical:
2. Application Rate:
EPA Registration No. ______________
3. Application Method: Backpack Sprayer/Blower
Aerial _________
Tractor Mounted Sprayer/Blower Other: __________________________________________________
9 Yes
9 No
4. Will you apply the chemical yourself?
If yes, indicate your Grower Permit #
, or your Private Certification # _____________
9 Yes
9 No
5. Will you hire someone other than yourself to apply the chemical?
If yes, list the applicator=s Custom Applicator=s License ________________________________________
or Commercial Certification #_____________________________________________________________
Applicator=s Name: ______________________________________________________________________
__________________________________________________________________(___)_________________
Address
City
State
Zip Code
Phone Number
9 Yes
9 No
C. BURNING:
If yes, attach a copy of the Land Department (ASLD), Natural Resources Conservation Service (NRCS), or
Southwest Interagency Fire Council Prescribed Fire Committee (SWIFCO) prescribed burning plan and
report.
6. RESEEDING:
A. Is treated area to be reseeded? 9 Yes
9 No
1. Seed mixture by species ___________________________________________________________________
2. Application rate _________________________________________________________________________
3. Method of seeding _______________________________________________________________________
7. FUNDING:
9 Yes
9 No
A. Is this a cost share project?
1. If yes, with which agency and what type of agreement or contract? ________________________________
________________________________________________________________________________________
B. Attach a copy of the NRCS project plan.
8. LOCATION:
A. Indicate location of the treatment area on the map on page 3 or attach a topographic map.
2
6104-02/93 (Rev. 12/2009) Land Treatment
~
N
9. I HEREBY CERTIFY, UNDER PENALTY OF PERJURY, THAT THE INFORMATION AND STATEMENTS
CONTAINED HEREIN, TOGETHER WITH ALL EXHIBITS AND ATTACHMENTS ARE TRUE, CORRECT AND
COMPLETE AND THAT I/WE HAVE AUTHORITY TO SIGN THIS DOCUMENT.
SIGNATURE
________________________________________________________
________________________________________________________________
(Name of Corporation, Partnership, etc.)
Date
Signature of Lessee/Permittee (Individual)
Date
________________________________________________________
________________________________________________________________
Signature
Title
Signature of Lessee/Permittee (Individual)
Date
DEPARTMENTAL USE ONLY
9
1.
Application for Land Treatment is APPROVED.
9
2.
Additional Conditions are attached and made a part of this permission.
9
3.
The Land Treatment must be completed by _______________________________________ or WRITTEN APPROVAL to extend this permission must be
received from the Department.
9
4.
The Applicant must submit a REPORT OF IMPROVEMENTS WITH PRIOR APPROVAL to the Department within 10 days following the completion
of the Land Treatment.
STATE OF ARIZONA
STATE LAND COMMISSIONER
(SEAL)
By: _____________________________________________
Date
9
5.
Application for Land Treatment is DENIED. Order No.__________________________________________ Date_________________________________
9
6.
Application for Land Treatment is REJECTED for the following reason: ________________________________________________________________
____________________________________________________________________________________________________________________________________
3
6104-02/93 (Rev. 12/2009) Land Treatment