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MIN N E S 0 T A Environmental Health Division <br /> ' Drinking Water Protection Section <br /> P.O.Box 64975 <br /> St. Paul,Minnesota 55164-0975 <br /> DEPARTMENTo�NEAITH Phone: 651-201-4700 <br /> Source Water Protection Plan Implementation Grant Application— March, 2015 <br /> APPLICANT INFORMATION <br /> Public Water Supply System: City of Centerville PWSID: 10200036 <br /> Street Address: 1880 Main Street Apartment/Unit#: <br /> City: Centerville County: Anoka ZIP: 55038 <br /> Name of the Person who will serve as the Grant Contact: Mike Ericson <br /> Phone: 651-429- Fax: 651-429-8629 Email: mericson@centervillem <br /> 3232 n.com <br /> Federal Tax Id #: 41-1267014 <br /> PERSON AUTHORIZED TO SIGN APPLICATION AND GRANT AGREEMENT ON BEHALF OF THE PUBLIC WATER SUPPLIER <br /> Name: Mike Ericson Title: City Administrator <br /> AMOUNTS <br /> Total Cost of the Project: $ 10,000.00............................ <br /> Amount Requested from MDH (minimum$1,000 maximum$10,000, or <br /> $30,000 if 3 or more PWS-s apply jointly): $ 10,000.00.................................. <br /> € Check this box if you are currently under a MDH violation/compliance agreement/APO(administrative penalty order) <br /> WORK ITEM 1 <br /> For each work item to be funded under the grant, please provide the following information (use an additional page if necessary) <br /> X Check this box if the work is a continuation from a previous MDH grant <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 1. Describe the work that will be performed: The city extended watermain services to a manufactured housing development in 2014. <br /> This project serviced 37 homes in total. The city was successful in obtaining a similar grant last year and we were able to assist in <br /> sealing 17 of the 37 abandoned private wells. These wells were constructed between the years 1983-1985 and are all located within the <br /> city's DWSMA. <br /> If the work item is about managing one or more potential contaminant sources,are they located in the DWSMA? X Yes No <br /> la.Amount Requested for performing this Work: $10,000 <br /> 1b. Anticipated outcomes(products)of performing this work: Eliminate private wells in the DWSMA, reducing the number of possible <br /> contamination points to the city's public water supply. <br /> 1c. Measure number: See Wellhead Protection Plan (Part 2)Chapter 5, Goal II.,A. Please reference the MEASURE/OBJECTIVE <br /> number in the MDH source water protection approved plan (NOT the Draft Copy)or Intake protection plan that will be supported by <br /> this work item. Attach the page(s)that contain(s)the source water protection measure/objective; <br /> OR <br /> Reference the most recent SANITARY SURVEY and attach the page in that contains the action that will be supported by this work <br /> item. (Failure to submit the required documentation may result in disqualification) <br />