Ohio Water Pollution Control Fund (WPCLF)
HSTS NOMINATION FORM
To be eligible for assistance through the WPCLF, each project must be nominated and placed on the project priority list for the designated program year. To nominate a Home Sewage Treatment System (HSTS) project, complete this form and submit it as indicated. Applicants submitting incomplete forms will be notified and the project will not be listedunless a complete nomination form is submitted byAugust 31, 2017. Please direct any questions to Adam Pierceat (614) 644-3673 or at .
To be eligible for HSTS funding, the following requirements must be met:
- The local government entity must have an existing HSTS inspection program.
- The HSTS systems identified by the local government for replacement/sewer connection must be failing systems. Non-failing HSTS systems are not eligible.
Applicant/Community: / Name of applicant/community. /
Applicant Address: / Street.
City. / County.
Zip Code.
Authorized Official: / Name, title. /
Email address. / Contact number. /
Local Oversight: / Identify the local governmental agency that will oversee implementation of the HSTS program, if different from the applicant. /
Project Name: / Name of project. /
Project Description: / Provide a brief description of the project. Please attach a map of the project area. /
Requested Funds: / $ Indicate the amount of funds that you are requesting. Note, for PY2018, a community cannot request more than $200,000 for addressing failing HSTS systems.
Estimated HSTS System Statistics:
Number of Upgraded Systems: / Estimate the number of failing HSTS system that will be upgraded. /Cost per Upgrade: / $ Estimate the average cost per upgrade.
Number of Sewer Connections: / Up to 50% of the request can be used to connect failing HSTS households to adjacent sewer lines. Estimate the number of connections that will be made. /
Cost per Connection: / $ Estimate the average cost per connection.
Gallons/Day Improved: / On average, each Ohio household generate about 400 gallons of sewage per day. Estimate the total number of gallons per day that will be improved by addressing these failing HSTS systems. /
Authorization/Signature
By signing below, you are certifying that you are authorized by your elected or appointed official to submit this nomination form, and that the information is complete and accurate to the best of your knowledge. You are also agreeing to:
- Use an effective and efficient means to contact and solicit eligible local homeowner.
- Solicit, evaluate, and select local applicants, and confirm homeowner income.
- Work with local health districts and contractors on all aspects of systems permitting and installation.
- Certify and document that all funding conditions and system installation/permitting requirements will be met.
- Use generally accepted accounting practices to document the disbursement of payments to contractors.
- Prepare and file all project documentation required as conditions for the award of assistance.
- Enter into contracts for completion of the HSTS repair/replacement activities.
Name and title of signatory. / Date
As part of this submittal, the following information is necessary to help Ohio EPA review the required information.
- Submit a general location map of the project area. The map should be either a 7.5 minute USGS topographic map that shows all the project features or a more detailed map that shows all the project details.
- Submit a letter from the local health department/districtagreeing to participate in the project for PY2018.
Once signed and dated, please submit this complete form along with the abovementioned documents to:
ONLY electronic submittals will be accepted. If you have any questions, please contact Adam Pierceat (614) 644-3673 or at .