Page 73 - _ 180314 Special Yucaipa GSA Packet

San Bernardino County
Permits/Operations Support Division – Flood Control Section
825 East Third Street, Room 108
San Bernardino, CA 92415-0835
(909) 387-7995 – FAX (909) 387-1858

FLOOD CONTROL PERMIT APPLICATION

The undersigned hereby applies for permission to encroach upon District right-of-way to perform the following work. It is
understood that completing this application does not constitute permission to commence the work on District right-of-way.

Fully describe work to be performed within District right-of-way.
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**Is a WDID (Waste Discharge Identification) number required for this project? YES NO
If Yes, provide WDID number: __________________________ If no, provide justification:_________________
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Location of Work:
(Be Specific) _____________________________________________________________________________________

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Area (city/community): __________________________________ District Facility: _______________________________________

__________________________________________________ __________________________________________________
Permittee (PERMIT WILL BE ISSUED TO…..) Applicant / Designee for Permittee
ALL CORESPONDENCE WILL BE SENT TO DESIGNEE

__________________________________________________ __________________________________________________
Contact Title Address

__________________________________________________ __________________________________________________
Address City State Zip

__________________________________________________ __________________________________________________
City State Zip Applicant’s Representative (PRINT)

__________________________________________________ __________________________________________________
Phone # FAX # Phone # FAX #

__________________________________________________ __________________________________________________
Email Date

All applications shall be accompanied by 6 sets of plans, 2 sets of environmental approvals (if necessary), 3 sets of drainage calculations (if necessary)
which include the input file listing, and all applicable fees. The submittal shall also contain one CD copy containing all plans and calculations.
**Permit issuance will be withheld without the required information Rev 12/19/14

Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 69 of 226