2016 Source Water Protection Assistance Program

Kentucky Source Water Protection Program

Kentucky Division of Water

Wellhead Protection Program

Source Water Protection Assistance Program

Application Form

Kentucky Energy and Environment Cabinet

Department of Environmental Protection

Division of Water, Water Quantity Management Section

200 Fair Oaks Lane, 4th Floor

Frankfort, Kentucky 40601

(502) 564-3410

1.  Project Title: ______

2.  Project Contact:
Name
Agency/Organization
Street Address
City
State
Zip
Telephone Number
Email Address
3.  Water system information
Associated PWS #
PWS Name
Street Address
City
Zip
County
Area Development District
PWS Contact
Other
4.  Type of Project (Check all that apply)
Unused water well abandonment
BMP Installation
Implementation of management strategies already defined in protection plan
Additional funds to aid in active watershed protection activities
Public education/outreach
Other
5.  Does the water system have an approved Source Water or Wellhead Protection Plan? Yes No
6.  Project Summary (give an overview of the project including the main issue(s) to be addressed, how this project will be implemented, and the responsibilities of each partner (preparing reports, submitting reimbursements, etc.):
7.  Project Goals and Activities (what are your goals for this project and what steps will you take to achieve them):
8.  Project Partners (Attach letter of participation from each partner at the end of the application):

Include the following information for each partner:

Agency Name and Contact Person:

Agency Address:

Role/Contribution to Project:

Phone No:

E-mail address:

9.  Project Measures of Success (how will you demonstrate that the goals of the project have been met):
10.  Budget

Please expand on your estimated budget from the Proposal to a detailed budget. Final budget may be adjusted at the discretion of the Source Water Assessment and Protection Program.

Category / Task / Rate/hr / Hours / Cost $
Personnel
Labor
(Personnel’s Position or Name)
Supplies
Equipment
Contractual
Other
Total / $
11.  Milestone Schedule
Milestone / Begin Date / Completion Date
Ex. 1. Submit education materials to KDOW for approval / October 2016 / November 2016
2. Conduct environmental education sessions at schools / December 2016 / December 2016
12.  Additional Funding Sources (optional)
Source / Amount / Federal / Non-Federal / In-kind

13.  Grant Application Conditions

Completion of this section is required in order to receive funding consideration.

·  Applicant agrees that the proposed project will comply with all applicable state regulations YesN/A

·  Applicant agrees to obtain all applicable permits. Yes N/A

·  Reporting will be conducted in accordance with the legal contract. Yes N/A

·  All Project Partners have agreed to participate. Yes N/A

WARNING: Any application which is determined to be deficient, not eligible, or missing KEY components will not be considered for funding.

14.  Application Signature

I certify that the information contained in this document is complete and accurate to the best of my knowledge and agree to comply with all conditions of funding.

Signature of Lead Agency’s Authorized Representative / Date
Typed Name and Title / Telephone Number

Application form for Source Water Protection Assistance Program

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4/4/2016