NHDES-W-09-033
RSA: RSA 486:1, III
Location of the Project
(city, town, etc.)
The
(legal name of applicant)
___
(address of applicant)
Hereby makes pre-application to the State of New Hampshire for grant assistance for the construction of:
(project)
Provide a description of the need of the project and how it will protect public health, water quality and the environment (attach additional information if necessary): ______
______
______
Will the completed project result in increased septage disposal capacity, and therefore be eligible for additional grant money? Yes or No
COST INFORMATION
1. / Estimated Construction Costs ……………………………..……. / $2. / 5% Construction Contingency………...... ………..……. / $
3. / Estimated Engineering Costs……………………………………. / $
(if unknown, assume 15% of construction costs)
4. / Other (please specify) / …______... / $
Total Estimated Costs………………….. / $
Anticipated Construction Completion Date
Method of Project Funding (please specify)
(SRF loan, sale of bonds, operating budget, reserve fund, etc.)
PROJECT DATA
Population Served by Facility
Population Receiving Collection: / Resident Population / Non-Resident Population*Present / Projected / Projected Year / Present / Projected / Projected Year
At this facility
From system that discharges to this facility (if any)
*The portion of the population that does not live within the service area, but utilizes the system infrastructure. Non-resident population includes transient, seasonal, and commuter workers and tourists.
Has an energy audit been conducted at the facility? Yes ____ No ____ Planned____
If Yes or Planned, when? ______
RATIONALE FOR COST ESTIMATES
Are the cost estimates for the project supported by a document (e.g., facility plan, preliminary design report) that is signed by an engineer?
If yes, please reference the document and identify the engineer:
______
______
If no, please describe the rationale for the cost estimates (attach additional information if necessary): ______
______
______
______
______
______
______
APPLICANT INFORMATION
Name: ______Signature*: ______
Title: ______Date: ______
Email: ______Phone No.: ______
*Must be signed by applicant.
Return to: Beth Malcolm, Grants Management Section, NHDES
29 Hazen Drive, PO Box 95, Concord, NH 03302-0095
Email: ; Phone: (603) 271-2978
(603) 271-3503
PO Box 95, Concord, NH 03302-0095
www.des.nh.gov
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