2015-03-11 CC Packet - Laserfiche WebLink

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INSTRUCTIONS You may complete this form manually or electronically. Please print the information if you opt to do this manually. Once you are finished,you have three options for submitting the application form to the Minnesota Department of Health: Option 1- Mail the form to: Option 2- Fax the form to: Option 3- E-mail the form to: Ms. Cristina Covaischi Ms. Cristina Covaischi Cristina.Covalschi@state.mn.us SWP Grant Coordinator SWP Grant Coordinator Minnesota Department of Health (651) 201-4701 P.O. Box 64975 St. Paul, Minnesota 55164-0975 DEFINITIONS OF THE TERMS USED IN THIS FORM (IN THE ORDER ENCOUNTERED): Public Water Supply System means the name that is used by the Minnesota Department of Health to identify the public water supplier and that is associated with a public water supply system identification number. Name of the Grant Contact means the name of the individual who will be responsible for managing the grant. Telephone Number means the telephone number of the contact person that the Minnesota Department of Health can call during its regular business hours(M-F from 8:30 a.m.to 4:30 p.m.). E-mail means an internet address for the contact person that the Minnesota Department of Health can use to electronically transmit information related to the grant. Mailing Address means the mailing address of the Public Supply System that shall be used for correspondence with MDH. Name and Title of the Person Authorized to Sign the Grant Agreement on Behalf of the Public Water Supply System means a person who has authority to administer a financial agreement between the public water supplier and the Minnesota Department of Health. Total Grant Amount Being Requested means the sum of the costs of the work items that are identified in the grant application (1a + 2a + 3a +....) Work Item is the source water protection activity measure from the WHP pian that are to be performed under this part of the grant application. Fill one box for each activity included in the project; feel free to insert more boxes if needed. Amount requested for performing this work means the estimated amount requested by the grantee for completing the activity performed under this part of the application. Product(s) produced or anticipated outcomes of performing this work means the tangible results of performing the work that is funded by this grant. DWSMA—Drinking Water Supply Management Area; is the Minnesota Department of Health (MDH)approved surface and subsurface area surrounding a public water supply well that completely contains the scientifically calculated wellhead protection area. Correspondence from MDH or Section of the sanitary survey or page number(s)in the source water protection plan that reference the source water protection measures that will be supported by this work item—self-explanatory. Detailed Budget means a breakdown of costs with a detailed description of all costs. Costs must be based on a written estimate from the contractor/vendor and must be attached to the application.The total must match the dollar amount that is being requested.The number of hours column must be filled out only for activities that involve hiring of a consultant. Estimated start date means the date when you expect to start the work. To request this document in a different format please call Section Receptionist: 651-201-4700 or TTY: 651-201-5797