Page 83 - _ 180314 Special Yucaipa GSA Packet

NOTIFICATION OF LAKE OR STREAMBED ALTERATION

5. AGREEMENT TYPE
Check the applicable box. If box B, C, D, or E is checked, complete the specified attachment.
A. □ Standard (Most construction projects, excluding the categories listed below)

B. □ Gravel/Sand/Rock Extraction (Attachment A) Mine I.D. Number: ____________________________

C. □ Timber Harvesting (Attachment B) THP Number: _______________________________

D. □ Water Diversion/Extraction/Impoundment (Attachment C) SWRCB Number: ____________________________

E. □ Routine Maintenance (Attachment D)

F. □ CDFW Fisheries Restoration Grant Program (FRGP) FRGP Contract Number______________________

G. □ Master

H. □ Master Timber Harvesting

6. FEES

Please see the current fee schedule to determine the appropriate notification fee. Itemize each project’s estimated cost
and corresponding fee. Note: The Department may not process this notification until the correct fee has been received.
A. Project B. Project Cost C. Project Fee
1

2
3
4

5
D. Base Fee
(if applicable)
E. TOTAL FEE
ENCLOSED

7. PRIOR NOTIFICATION OR ORDER
A. Has a notification previously been submitted to, or a Lake or Streambed Alteration Agreement previously been issued
by, the Department for the project described in this notification?

□ Yes (Provide the information below) □ No

Applicant: ____________________________ Notification Number: _____________________ Date: _____________
B. Is this notification being submitted in response to an order, notice, or other directive (“order”) by a court or
administrative agency (including the Department)?

□ No □ Yes (Enclose a copy of the order, notice, or other directive. If the directive is not in writing, identify the
person who directed the applicant to submit this notification and the agency he or she represents, and
describe the circumstances relating to the order.)

□ Continued on additional page(s)

Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 79 of 226
FG2023 Page 2 of 9 Rev. 1/13