Page 80 - _ 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 AMENDMENT APPLICATION

PERMIT NO: _________________________________ CITY/COMMUNITY: ________________________________

FILE NO: ____________________________________ DISTRICT FACILITY: ______________________________________

The undersigned hereby applies for permission to amend the above noted permit to perform the following work. It is understood that
completing this application doesnot constitute permission to commence the work on District right-of-way.

Describe type of work performed within District right-of-way under original permit:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_________________________________________________________________________________

**Is coverage under the State Construction General Permit required for this project?
(http://www.swrcb.ca.gov/wter_issues/programs/stormwater/construction.shtml) YES NO
If Yes, provide WDID number: __________________________ If no, provide justification:_________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

CHECK ALL THAT APPLY:

Permittee Name Change To: ___________________________________
Name

Time Extension To: ___________________________________
Date

Revision to Permitted Activity
(Describe Proposed Revision,
Including Location of Work): _____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________

__________________________________________________ __________________________________________________
Permittee (PERMIT AMENDMENT WILL BE ISSUED TO…..) Applicant (AGENT FOR PERMITTEE)

__________________________________________________ __________________________________________________
Contact Title Address

__________________________________________________ __________________________________________________
Address City State Zip

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

__________________________________________________ __________________________________________________
Phone # FAX # Phone # FAX #

__________________________________________________
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 Amendment issuance will be withheld without the required information Rev 08/11/14
Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 76 of 226