NCFSWC Inactive Animal Waste Lagoon Closure Program Application
November 2016 Page 1 of 3
Foundation Grant Application Form
EEGP Inactive Animal Waste Lagoon Closure Program
Applicant Information
Name of Conservation District
District Board Chairperson
Name and Title of Staff Contact Person
Telephone Email
Mailing Address
Financial Information
Budget (Income and Expenses) of your Conservation District funds (Salary/travel/office supplies, etc) for the last three years:
YEAR
INCOME $ $ $
EXPENSES $ $ $
List the District’s top three projects in the past three years (EQIP, ACSP, AgWRAP, CCAP, singular grants, etc.)?
Funding Source Project Amount Encumber Date Completion Date
Proposed Project Information
Foundation Program Category: Improving the Natural Environment
This Project’s Name
Lagoon Operation Type Facility Number Lagoon Number Surface Acres
Project Address
Person in Charge of Project at site and Title
Mailing Address
Telephone Email
Amount Requested of the Foundation for this Project: $ Total Project Budget: $
Other Sources of Funding for the Project:
SourceAmount RequestedAmount Committed
$ $
$ $
$ $
Period of Time this Grant will be used: Month/Year start Month/Year end
Problems/Factors supporting the need to close this inactive animal waste lagoon (check all that apply)
1. The lagoon is within a delineated 100-year floodplain.
2. The lagoon is in a public water supply watershed, presenting an elevated threat to polluting water supply.
3. The lagoon is adjacent to or near a stream included on the State’s 303d list.
4. The lagoon is within a natural resource concern priority area set by the District or local planning agencies.
5. Excess water drains into lagoon creating a high risk of overflow or breach and polluting nearby streams.
6. The lagoon has structural problems (i.e. excessive erosion, gullies, uneven settlement of dike, etc.).
7. The lagoon has trees or other vegetation growing on the structure endangering its stability.
8. The lagoon is leaking through the dike and/or shows indications of potentially polluting groundwater.
9. The lagoon has an unresolved notice(s) of violation.
10. The lagoon is listed on a reputable survey as a site needing closure or major repairs.
11. The lagoon has been inactive/out of use for less than one year OR more than one year.
12. The land user wants to close the lagoon for public benefit OR personal convenience.
13. The NPDES Permit for this lagoon has expired or the lagoon was never permitted.
14. Additional factor
15. Additional factor
How will this inactive lagoon site be used after the proposed closure has been completed? (Attach page if needed)
Certification and Signatures
Does your Conservation District have a Formal Policy on Compliance with Civil Rights Laws concerning Equal Employment Opportunities and Access to Public Programs? Yes No
Our District Board of Supervisors understands that to be considered for funding, this application including the proposal summary must be completed in its entirety and all attachments referenced in the Foundation’s grant program guidelines must be provided. We certify that we will execute the project as approved and on a schedule mutually agreed to by and between the District and the Foundation.
This application for financial support from the Foundation was approved by official action of the District’s Board of Supervisors during a meeting held on
Signed By:
Chairperson Date
2ndBoard Member Date
PROPOSAL Narrative - This Section Must Be Completed Using This Form
Name of Conservation District:
Title of Project: Amount Requested:
In the space below, briefly describe your project, its purpose, and plan of action. Describe how you will use the Foundation grant and all other funds identified in your proposal to complete the project. This summary shouldsupport the details included in the application package. Use this space to provide any additional information not shown otherwise in support of your request for funds.
(Do Not Exceed One Page)