Page 82 - _ 180314 Special Yucaipa GSA Packet
P. 82
FOR DEPARTMENT USE ONLY
Date Received Amount Received Amount Due Date Complete Notification No.
$ $
STATE OF CALIFORNIA
DEPARTMENT OF FISH AND WILDLIFE
NOTIFICATION OF LAKE OR STREAMBED ALTERATION
Complete EACH field, unless otherwise indicated, following the enclosed instructions and submit ALL required
enclosures. Attach additional pages, if necessary.
1. APPLICANT PROPOSING PROJECT
Name
Business/Agency
Street Address
City, State, Zip
Telephone Fax
Email
2. CONTACT PERSON (Complete only if different from applicant)
Name
Street Address
City, State, Zip
Telephone Fax
Email
3. PROPERTY OWNER (Complete only if different from applicant)
Name
Street Address
City, State, Zip
Telephone Fax
Email
4. PROJECT NAME AND AGREEMENT TERM
A. Project Name
□ Regular (5 years or less)
B. Agreement Term Requested
□ Long-term (greater than 5 years)
C. Project Term D. Seasonal Work Period E. Number of Work Days
Beginning (year) Ending (year) Start Date (month/day) End Date (month/day)
Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 78 of 226
FG2023 Page 1 of 9 Rev. 1/13
