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2. First Name *
3. Last Name*
4. Mailing Address*
6. Email Address*
7. Phone Number
9. Agent or Responsible Party First Name*
10. Last Name*
11. Mail Addresss*
13. Email Address*
14. Phone Number
16. Street Address*
17. Legal Description*
    Please include Subdivision Lot and Block # or Township Range Section
18. Parcel Number
20. Please give a brief description of what the project is about*
22. Attach the following documentation:
    A. Information in sufficient detail to determine if the proposed site alteration activity qualifies as a categorical exclusion including but not limited to graphic representation of the proposal which shall include property lines and delineate the proposed areas for improvement or alteration, proposed and existing structures and land uses. B. A request for categorical exclusion for any building, access road and or driveway that is not visible from a reference road shall include and demonstrate, in addition to all other requirements, re-vegetation with native or native compatible vegetation to prevent erosion, compliance with all applicable road and driveway standards including all applicable grade standards, appropriate measures or design features to prevent soil erosion, silting of lower slopes, slide damage and flooding and any other geological instability, and approval from the applicable fire district Marshall and the South Central Health District for on-site sewage disposal. C. A request for categorical exclusion for the maintenance, repair and improvement of any building, other structure or hillside road that was in existence and lawful before December 18, 1991, or lawfully constructed thereafter shall demonstrate appropriate measures or design features to prevent soil erosion, silting of lower slopes, slide damage, flooding and any other geologic instability. D. Include map showing names of surrounding landowners within 300 feet of the exterior boundary of subject property, including private road owners. Attach names and addresses of surrounding landowners, including private road owners, typed on mailing labels. Information is available from County Assessors Office. Please add current postage + .15¢ per surrounding landowner mailing fee. E. Processing fee of $175.00 as established by County Resolution #2001-54.
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24. 1. Receive an email copy of this form.
25. Email address

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26. Submit

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