ࡱ> ` Zbjbjss f$+@@@@@@@$d111P2$<3d[3< >(H>H>H>H>JF&KLYYYYYYY$[hR^Y@rMH>H>rMrMY@@H>H>ZpVpVpVrMp@H>@H>YpVrMYpVpVX@@XH>3 ϕ1MXYZ0[X, _NB _X _@X rMrMpVrMrMrMrMrMYYVXrMrMrM[rMrMrMrMdddd"1ddd1ddd@@@@@@ APPLICATION FORM FOR PROJECT ASSISTANCE FROM THE UTAH STATE WATER QUALITY BOARD Application Number: (LEAVE BLANK-FOR STATE USE ONLY) Preapplication Meeting Date: PROJECT IDENTIFICATION AND DESCRIPTION 1. APPLICANT:  FORMTEXT       (Municipality, Sewer District, Special Improvement District, etc.) Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       EIN #  FORMTEXT       Phone:  FORMTEXT       2. PRESIDING OFFICIAL:  FORMTEXT       (Name and Title) 3. CONTACT PERSON:  FORMTEXT       (Name and Title) 4. TREASURER/RECORDER:  FORMTEXT       (Name and Title) 5. CONSULTING ENGINEER:  FORMTEXT       (Name and Title) Name of Firm:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       EIN #  FORMTEXT       Phone:  FORMTEXT       6. BOND COUNSEL:  FORMTEXT       (Name and Title) Name of Firm:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       Phone:  FORMTEXT       7. FINANCIAL ADVISOR:  FORMTEXT       (Name and Title) Name of Firm:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       Phone:  FORMTEXT       For the following questions please attach explanations on a separate sheet if adequate space is not provided on this form. 8. DESCRIPTION OF PROJECT SETTING A. Location of the Project:  FORMTEXT       B. County:  FORMTEXT       9. GENERAL PROJECT OVERVIEW A. Description of the project:  FORMTEXT       (1) Year construction will be initiated:  FORMTEXT       (2) Year of completion:  FORMTEXT       (3) Total project cost: $ FORMTEXT       B. Position on the Utah Priority List # FORMTEXT       List Date:  FORMTEXT       C. Explain why project is needed:  FORMTEXT       D. State and Federal water quality and public health regulations to be addressed by the project:  FORMTEXT       E. What good faith efforts to secure all of part of services and funds from the other funding agencies:  FORMTEXT       F. Public participation:  FORMTEXT       (meetings, fact sheets, referenda, etc.) G. Describe Demonstrations of Public support for project:  FORMTEXT       H. Type of planning document prepared:  FORMTEXT       (Facility plan, engineering report, etc.) Planning Document Date:  FORMTEXT       (Note: Enclose a copy of current planning document.) FINANCIAL ASSESSMENT - ESTIMATED ANNUAL COST OF SEWER SERVICES 1. PROJECT COST ESTIMATE: A. Construction (1) Wastewater treatment plant: $  FORMTEXT       (2) Pump stations: $  FORMTEXT       (3) Interceptor sewers: $  FORMTEXT       (4) Collection sewers: $  FORMTEXT       (5) Small systems (neighborhood or community septic tanks): $  FORMTEXT       (6) Land acquisition: $  FORMTEXT       (7) Other (specify): FORMTEXT       $  FORMTEXT       (8) Other (specify): FORMTEXT       $  FORMTEXT       (9) Other (specify): FORMTEXT       $  FORMTEXT       (10) Other (specify): FORMTEXT       $  FORMTEXT       (11) Total Construction Costs: (1.A(11)) $  FORMTEXT       B. Other Project Costs: (1) Engineering - Planning $  FORMTEXT       (2) Engineering - Design $  FORMTEXT       (3) Engineering - CMS $  FORMTEXT       (4) Engineering - Other $  FORMTEXT       (5) Legal  Bonding $  FORMTEXT       (6) Legal - Rights of Way & Easements $  FORMTEXT       (7) Other (specify): FORMTEXT       $  FORMTEXT       (8) Other (specify): FORMTEXT       $  FORMTEXT       (9) Other (specify): FORMTEXT       $  FORMTEXT       (10) Other (specify): FORMTEXT       $  FORMTEXT       (11) Total Other Costs: (1.B(11)) $  FORMTEXT       2. ESTIMATED ANNUAL COSTS: B. Operation & Maintenance Costs of the Proposed Facility* (1) Labor: $  FORMTEXT       per year (2) Utilities: $  FORMTEXT       per year (3) Materials: $  FORMTEXT       per year (4) Contracted services (i.e. laboratory): $  FORMTEXT       per year (5) Miscellaneous expenses: $  FORMTEXT       per year (6) Equipment replacement: $  FORMTEXT       per year (7) Total OM&R costs: (2.B)(7) $  FORMTEXT       per year *Include current O&M costs which will continue with the new facility C. Existing annual debt service: $  FORMTEXT       per year (for sewer services only, attach a copy of debt authorization schedules) D. Estimate costs for installation of individual service laterals (if the project includes a new collection system): $  FORMTEXT       3. FINANCING THE NEW FACILITIES A. 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Other Project Costs (from 1.B.(10)): $  FORMTEXT       C. TOTAL PROJECT COSTS $  FORMTEXT       D. Funds available for the project (reserve accounts, contingency, etc.): $  FORMTEXT       E. Grants (specify agencies and status of funds):  FORMTEXT       $  FORMTEXT        FORMTEXT       $  FORMTEXT       F. Other sources of funding (specify):  FORMTEXT       $  FORMTEXT        FORMTEXT       $  FORMTEXT        FORMTEXT       $  FORMTEXT       G. TOTAL FUNDS AVAILABLE $  FORMTEXT       H. AMOUNT TO BE FINANCED (from 3.C - 3.G.): $  FORMTEXT       4. BOND MARKET FORECAST INFORMATION A. Estimated terms your project would be required to meet if project was financed through the sale of a bond on the open market. Interest Rate:  FORMTEXT       Term:  FORMTEXT       Principal Amount: $  FORMTEXT       Source:  FORMTEXT       Comments:  FORMTEXT       5. DEBT STRUCTURE OF YOUR COMMUNITY A. Legal general obligation debt limit: (1) Assessed Valuation: $  FORMTEXT       x 12% = $  FORMTEXT       (2) Less: Current Annual General Obligation Debt: $  FORMTEXT       (3) Available General Obligation Debt Limit (1)-(2) $  FORMTEXT       6. DEMOGRAPHIC OUTLINE A. Population Estimates: (1) Current Population:  FORMTEXT       (2) Population in 1990:  FORMTEXT       (3) Estimated Population in 2000:  FORMTEXT       (4) Planning Year Population:  FORMTEXT       (5) Planning Year:  FORMTEXT       (6) Source of Estimates:  FORMTEXT       B. Current Cost of Sewer Service: (1) Current basic, monthly user charge: Residential $  FORMTEXT       Commercial $  FORMTEXT       Industrial $  FORMTEXT       (2) If user charges are based on water usage: Base Rate $  FORMTEXT       /  FORMTEXT       Gallons Overage Rate $  FORMTEXT       /  FORMTEXT       Gallons (3) If property tax, or other tax, is levied to fund sewer debt, operation or maintenance: Tax Rate (for sewer only)  FORMTEXT       Assessed Valuation $  FORMTEXT       Annual Revenue from Taxes $  FORMTEXT       (4) Is sewer service subsidized by any other source of revenue not previously mentioned, please explain:  FORMTEXT       C. Impact & Hookup Fees: (1) Current Impact Fee: $  FORMTEXT       (2) Current Hookup Fee: $  FORMTEXT       (3) Have you completed a Capital Facilities Plan which meets the requirement of the Utah Impact Fee Act? Yes:  FORMCHECKBOX  No:  FORMCHECKBOX  Please attach a copy of the Capital Facilities Plan D. Current number of equivalent residential connections:  FORMTEXT       (1) Last year s annual sewer user charge revenue: $  FORMTEXT       (2) Last year s annual, residential, user rate: $  FORMTEXT       (3) Revenue Divided by User Rate (1)/(2)*  FORMTEXT       *a rough estimate of residential equivalent connections E. Median Adjusted Gross Income (to be completed by DWQ staff) Year: MAGI: F. Major Industries and approximate percent of workforce employed by each:  FORMTEXT        FORMTEXT        FORMTEXT       G. Please list additional capital intensive projects which your community is planning or will require in the near future? (Please include such needs as schools, roads, water systems, parks, municipal buildings, etc.) Project DescriptionProjected Construction DateEstimated Cost FORMTEXT       FORMTEXT      $  FORMTEXT       FORMTEXT       FORMTEXT      $  FORMTEXT       FORMTEXT       FORMTEXT      $  FORMTEXT       H. Please provide audited financial statements for the past two years and a copy of your current operating budget. I. Please provide a copy of your current sewer rate ordinance and user charge system. Signature of person responsible for completion of this form:  FORMTEXT       Signature of Authorized Representative:  FORMTEXT       REMINDER Have you remembered to enclose the following: 1. Facility Plan or other planning documents. 2. Amortization table for each outstanding debt. 3. Financial statements for the past 2 years plus this year's current budget. 4. Current sewer rate ordinance and user charge system. 5. Capital Facilities Plan which meets the Utah Impact Fee Act. 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be completedDText34Type project costType project costD Text35Position on Utah Priority ListPosition on Utah Priority ListDText36Date of Priority ListDate of Priority ListDText37)Explaination of why the project is needed)Explaination of why the project is neededDText38\State and Federal water quality and public health regulations to be addressed by the project\State and Federal water quality and public health regulations to be addressed by the project&DText39lDescribe what good faith efforts to secure all of part of services and funds from the other funding agencieslDescribe what good faith efforts to secure all of part of services and funds from the other funding agenciesDText40LDescribe public participation such as meetings, fact sheets, referenda, etc.LDescribe public participation such as meetings, fact sheets, referenda, etc.JDText415Describe Demonstrations of Public support for project5Describe Demonstrations of Public support for projectDText42ZWhat type of planning document (Facility plan, engineering report, etc) is being prepared?ZWhat type of planning document (Facility plan, engineering report, etc) is being prepared?DText43Date of Planning DocumentDate of Planning DocumentDText44"cost of wastewater treatment plant"cost of wastewater treatment plantDText45Cost of Pump StationsCost of Pump StationsDText46Cost of Interceptor sewersCost of Interceptor sewersDText47Cost of Collection sewersCost of Collection sewersnDText48>Cost of small systems (neighborhood or community septic tanks)>Cost of small systems (neighborhood or community septic tanks)DText49Cost of land acquisitionCost of land acquisitionDText50Specify "other"Specify "other"DText51Cost of "otherCost of "otherDText52Specify "other"Specify "other"DText53Cost of "otherCost of "otherDText54Specify "other"Specify "other"DText55Cost of "otherCost of "otherDText56Specify "other"Specify "other"DText57Cost of "other"Cost of "other"DText58Total cost of constructionTotal cost of constructionDText59Cost for Engineering - PlanningCost for Engineering - PlanningDText60Cost for Engineering - DesignCost for Engineering - DesignDText61Cost for Engineering - CMSCost for Engineering - CMSDText62Cost for Engineering - OtherCost for Engineering - OtherDText63Legal cost - BondingLegal cost - Bonding DText64%Legal cost - rights-of-way, easements%Legal cost - rights-of-way, easementsDText65Specify "other"Specify "other"DText66"Other" project cost"Other" project costDText68Specify "other"Specify "other"DText67"Other" project cost"Other" project costDText69Specify "other"Specify "other"DText72"Other" project cost"Other" project costDText70Specify "other"Specify "other"DText71"Other" project cost"Other" project costDText73Total "Other" costsTotal "Other" costsDText74O & M costs for LaborO & M costs for LaborDText75O & M costs for UtilitiesO & M costs for UtilitiesDText76O & M costs for MaterialsO & M costs for MaterialsNDText776O & M costs for constracted services (i.e. laboratory)6O & M costs for constracted services (i.e. laboratory)DText78O & M Miscellaneous expensesO & M Miscellaneous expensesDText79 O & M equipment replacement cost O & M equipment replacement costDText80Total cost of OM & RTotal cost of OM & RFDText814Existing annual debt service for sewer services only4Existing annual debt service for sewer services onlyDText82]Cost of installing individual sewer laterals if the project includes a new collection system ]Cost of installing individual sewer laterals if the project includes a new collection system DText83&Total construction cost (from 1.A(11))&Total construction cost (from 1.A(11))DText84#Other Project Costs (from 1.B.(10))#Other Project Costs (from 1.B.(10))DText85Total project costsTotal project costsDText86EFunds available for the project (reserve accounts, contingency, etc.)EFunds available for the project (reserve accounts, contingency, etc.)D(Text87*Grant - Specify agency and status of funds*Grant - Specify agency and status of fundsDText89 Grant amount Grant amountD(Text88*Grant - Specify agency and status of funds*Grant - Specify agency and status of fundsDText90 Grant amount Grant amountD(Text91Specify other source of fundingSpecify other source of fundingDText92Other funding amountOther funding amountD(Text93Specify other source of fundingSpecify other source of fundingDText94Other funding amountOther funding amountD(Text95Specify other source of fundingSpecify other source of fundingDText96Other funding amountOther funding amountDText97Total funds availableTotal funds availableDText98'Amount to be financed (from 3.C - 3.G.)'Amount to be financed (from 3.C - 3.G.)DText99Interest Rate of bondInterest Rate of bondDText100 Term of bond Term of bondDText101Principal amount of bondPrincipal amount of bondD-Text102Source of bondSource of bondDText103Comments about bondComments about bondxDText104\DText1059Calculated amount of assessed valuation multiplied by 12%9Calculated amount of assessed valuation multiplied by 12%8DText1060Amount of Current Annual General Obligation Debt0Amount of Current Annual General Obligation Debt4DText107/Available General Obligation Debt Limit (1)-(2)/Available General Obligation Debt Limit (1)-(2)DText108Current populationCurrent populationDText109Population in 1990Population in 1990DText110Estimated population in 2000Estimated population in 2000DText111Planning year populationPlanning year populationDText112 Planning year Planning yearDText113Source of estimatesSource of estimates`DText114:Current basic montly user charge for residential customers:Current basic montly user charge for residential customers\DText1159Current basic montly user charge for commercial customers9Current basic montly user charge for commercial customers\DText1169Current basic montly user charge for industrial customers9Current basic montly user charge for industrial customersDText117 Base Rate Base RateDText118&# of gallons used to express Base Rate&# of gallons used to express Base RateDText119#Dollar amount 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