Applicationforlandprotection Grant Project Eligibility

APPLICATIONFORLANDPROTECTION GRANT PROJECT ELIGIBILITY

(pursuant to Env-Dw 1002)

SUBMIT:ONE COMPLETED APPLICATION WITH SUPPORTING INFORMATION

TO:Holly Green, WaterSupplyLand Protection Grant Program Coordinator

NHDepartment of Environmental Services

Drinking Water and Groundwater Bureau

29 Hazen Drive, P.O. Box 95

Concord, NH03302-0095

FAX: 271-0656

Note: Complete a separate Section Two form for each parcel to be protected, including match properties.

If you have any questions, please contact the Water Supply Land Grant Program Coordinator, Holly Green at (603) 271-3114or DWGB Bureau Administrator, Sarah Pillsbury, at (603) 271-1168.

SECTION ONE

I.APPLICANT

Name Telephone

Mailing Address

City/Town: State: Zip: ______

E-mail and/or web page: ______

Applicant status (must be one of the following):

____ NH municipality (includes village & school districts)

____ Non-profit organization having water supply as a principal mission (attach copy of IRS tax exempt

notification letter)

____ Non-profit organization having land conservation as a principal mission (attach copy of IRS tax exempt notification letter)

II.CONTACT PERSON

Name: ______Telephone:______

Mailing Address: ______

City/Town: State: Zip: ______

E-mail: ______Fax: ______

III. DESCRIPTION of the active or proposed Source of Public Drinking Water that will be protected

a. US EPA Public Water Supply ID # (if known)______

If ID # is not known, please write a description of the source of public drinking water that will be protected:

______

b. Total number of sources being protected ______

IV. Is this land or conservation easement being purchased from a willing seller?______

V. MATCH INFORMATION

List each component of the proposed match, its type (public funds, private funds, donated land

or easements by owner, protection costs), its status (whether authorized, received or anticipated), the

value of each match component and the total match value:

(Note: Match parcels that have already been permanently protected more than one year prior to the date of eligibility application submittal are not eligible).

Match Type/Owner / Match Status / Match Value
TOTAL $

(Note: a separate section 2 form needs to be completed for every match parcel)

b. Percent match supplied by applicant ______%

c. What is the source of the grantee’s cash contribution? ______

d. Will the Drinking Water State Revolving Fund be used? ______

If yes, anticipated amount? ______

VI.GENERAL INFORMATIONON LAND PARCELS

List all parcels to be acquired with water supply land protection grant funds.

(Note: Grant parcels which are the already permanently protected or owned by the grantee are not eligible).

Parcel / Funding Amount Sought
Total $

(Note: a separate section 2 form needs to be completed for all parcels being acquired).

VII.LOCAL APPROVAL

a. Indicate the date when the local governing body of the municipality approved or is scheduled to approve applying for this grant.

______

SECTION TWO

VII. DETAILED INFORMATION ON LAND PARCELS

Complete this section for each separate parcel to be protected, including match propertiesand for each parcel owned by a different landowner:

a. Total number of Section Two forms being completed for the project ______

b. Is this Section Two form is being completed for: parcel to be acquired with grant funds ______

parcel that will be part of the required match ____

Parcel Information

a. Owner

Name: ______Telephone: ______

Mailing Address: ______

City/Town: ______State: ______Zip: ______

b. Location of the Parcel or Topographic Map (applicant may submit GIS shape files in lieu of this info.)

Address:

City/Town:State:Zip:

County: ______

Tax Map: Lot # ______

Deed Reference: Book ______Page ______

c. Acreage of parcel:______

d. Acreage in parcel proposed for protection:______

e. Provide detailed instructions on how to gain access to the property to view it: ______

______

Describe proposed land uses for the property. ______

Distance of parcel boundary from the water supply source being protected ______

Length of riparian frontage (as defined in Env-Dw 1002.02(o)) ______

Description of the water supply protection value of the property: ______

______

Describe the property’s conservation values: (attach separate page if necessary)

i. Water quality protection value: watershed; surface water; length of undeveloped shoreline on pond, lake, stream, or navigable river; wetlands; or floodplain, including whether the parcel contains or abuts natural pond(s) greater than 10 acres, perennial streams or rivers, non-forested wetlands, or floodplains greater than 5 acres: ______

______

ii. wildlife and management potential, significant habitat, rare and threatened animal and plant species, exemplary natural communities (including: whether the parcel contains or abuts state or federally listed threatened or endangered species; habitat for such species that have been determined by the NH Fish and Game Dept to be critical; or rare plants, animals, or exemplary natural communities that have been identified by the NH Heritage Bureau): ______

iii. undeveloped land value, including whether the parcel abuts existing conservation land, such that there is an unfragmented block of undeveloped land 500 acres or more:

______

iv. agricultural value, including important farmland according to the US Department of Agriculture, Natural Resources Conservation Service: ______

v. existing or potential outdoor public recreational amenities, such as public trails and public boat access points: ______

vi. historical, cultural, archaeological values, including it is on the National Register of Historic Places or identified by the NH Dept of Cultural Resources, Div of Historical Resources: ______

vii. any other identified conservation value, such as forestry and scenic views:

______

Include a sketch of: a) source water protection area; b) parcel; and, c) area proposed for protection(if different) on a USGS topographic map or on your municipal drinking water resource map.Geographic Information Systems (GIS) shape file(s) may be submitted in lieu of sketch.

List all structures, impoundments, gravel pits or other disturbances, and any known or potential contamination sources on the property: ______

Describe current land cover (e.g., % forest, field, wetlands) and use: ______

Proposed transaction type: Full Ownership (Fee Simple) ______

Conservation Easement______

Proposed owner of land:______

If applicable, proposed holder of conservation easement______

Assessed value of land or easement proposed for protection $______

Estimated fair market value $______

The price at which the landowner will sell the property$______

The estimated expense(s) for land being used as match $______

Funding request from DES for this parcel $______

SECTION THREE

VIII. WATER SUPPY SOUCE INFORMATION

Identify water supply source measures that are in effect by public water supply system and/or municipality in which water supply source is located:

Comprehensive source water protection program plan being implemented(attach if available):______

Source water protection area regulations in effect:______

Source water protection area educational program in effect:______

Established land acquisition plan in source water protection area:______

Existing source water protection area ownership beyond sanitary radius or control through easement by water suppliers or others:______

Long term plan for meeting system demand:______

Water conservation plan being implemented:______

SECTION FOUR

IX. SUPPORTING INFORMATION. Please submit the following information with the application:

a. A USGS topographic map or other map which identifies: the applicable source water protection area(s); if applicable, the sanitary radius;, the property to be acquired with the grant; any match properties; any property owned or otherwise protected by the applicant; any other protected lands, and any protected land within the source water protection area.

b. A property map of each parcel proposed for protection under this application, at a scale which ensures that all details are legible, which identifies all structures or land alterations, utilities and wells, roads or trails, gravel pits or disturbed areas, easements or rights-of-way, and the approximate areas of field, forest, wetlands and surface waters.

c. If applicable, a copy or web page link to source water protection plan(s).

d. If applicable, a copy or web page link to source water protection regulations.

e. If applicable, any available hydrogeologic information about proposed water supplies.

CERTIFICATION STATEMENTS

APPLICANT:

To the best of my knowledge, the data and information which I have submitted to qualify for the grant from the

New Hampshire Department of Environmental Services are true and correct.

Date: ______Signed: ______

Applicant (or authorized agent)

Name and Title: ______

LANDOWNER(S):

Based on the data and information submitted herein, I acknowledge my willingness to enter into negotiations

for the acquisition of this property and certify that all liens and encumbrances on the property are listed below:

Liens and Encumbrances: ______

______

Date: ______Signed: ______

Landowner(s)

Note: This statement shall be deemed confidential under the provisions of RSA 91-A:5, IV and shall not be

disclosed to any party other than necessary department staff without the written consent of the applicant, until suchtime that the grant application has been selected for grant funding.