DWQ-2025-000220

APPLICATION FORM FOR PROJECT ASSISTANCEFROM THE UTAH WATER QUALITY BOARDI. PROJECT IDENTIFICATION AND DESCRIPTIONAPPLICANT(Municipality, Sewer District, Special Improvement District,
etc.)AddressCity StateZip Code PhoneEmailEIN #UEI# (from sam.gov)PRESIDING OFFICIAL (Name and Title)AddressCity StateZip Code PhoneEmailCONTACT PERSON (Name and Title)Phone EmailTREASURER/RECORDER
(Name and Title)CONSULTING ENGINEER (Name and Title)Name of FirmAddressCity StateZip Code PhoneEmailBOND COUNSEL(Name and Title)Name of FirmAddressCity StateZip Code PhoneEmailFINANCIAL
ADVISOR(Name and Title)AddressCityStateZip Code PhoneEmailFor the following questions please attach explanations on a separate sheet if adequate space is not provided on this form.DESCRIPTION
OF PROJECT SETTINGLocation of the ProjectCounty GENERAL PROJECT OVERVIEWDescription of the project Year construction will be initiated Year of completion Total project cost $Explain
why project is needed State and Federal water quality and public health regulations to be addressed by the project What good faith efforts to secure all or part of services and funds
from the other funding agencies Public participation(meetings, fact sheets, referenda, etc.)Describe Demonstrations of Public support for project Type of planning document prepared (Facility
plan, engineering report, etc.)Planning Document Date (Note: Enclose a copy of the current planning document.)II. FINANCIAL ASSESSMENT - ESTIMATED ANNUAL COST OF SEWER SERVICESPROJECT
COST ESTIMATEConstructionWastewater treatment plant$Pump stations$Interceptor sewers$Collection sewers$Land acquisition$Other (specify)$Other (specify)$Other (specify)$Contingency for
Construction*$Total construction costs (1.A(11))$*Construction projects should include a contingency amountOther Project CostsEngineering - Planning$Engineering - Environmental Review$Engineering
- Design$Engineering - CMS$Engineering - Other$Legal - Bonding$Legal - Rights of Way & Easements$Other (specify)$Other (specify)$Other (specify)$Contingency for Engineering$Total Other
Costs (1.B(11))$ESTIMATED ANNUAL COSTSOperation & Maintenance Costs of the Proposed Facility*Labor$ per yearUtilities $ per yearMaterials$ per yearContracted services (i.e. laboratory)$
per yearMiscellaneous expenses$ per yearEquipment replacement$ per yearTotal OM&R costs (2.A)(7)$ per year*Include current O&M costs which will continue with the new facilityExisting
annual debt service $ per year
(for sewer services only, attach a copy of debt authorization schedules)FINANCING THE NEW FACILITIESTotal construction cost (from 1.A(11))$Other Project Costs (from 1.B.(11))$TOTAL PROJECT
COSTS$Funds available for the project(reserve accounts, contingency, etc.)$*Grants (specify agencies and status of funds)*If you have or will receive a “Direct Award Grant” (see Title
63G-6b-401) for the same purpose you are not eligible for a State competitive grant from the Utah Water Quality Board. You must notify DWQ if you have, or do in the future receive a
Direct Award Grant as defined in Title 63G-6b-101.$$Other Sources of Funding (specify)$$$TOTAL FUNDS AVAILABLE$AMOUNT TO BE FINANCED (from 3.C - 3.G)$BOND MARKET FORECAST INFORMATIONEstimated
terms your project would be required to meet if the project was financed through the sale of a bond on the open market.Interest Rate Term Principal Amount Source Comments DEBT STRUCTURE
OF YOUR COMMUNITYLegal general obligation debt limit(1)Assessed Valuation $ x 12%$(2)Less: Current Annual General Obligation Debt$(3)Available General Obligation Debt Limit (1)-(2)$DEMOGRAPHIC
OUTLINEPopulation EstimatesCurrent PopulationPopulation from ten years agoEstimated Population in twenty yearsPlanning Year PopulationPlanning YearSource of EstimatesCurrent Cost of
Sewer ServiceCurrent basic, monthly user chargeResidential$Commercial$Industrial$If user charges are based on water usageBase Rate$ /GallonsOverage Rate$
/GallonsIf property tax, or other tax, is levied to fund sewer debt, operation or maintenanceTax Rate (for sewer only)Assessed Valuation$Annual Revenue
from Taxes$Is sewer service subsidized by any other source of revenue not previously mentioned, please explainImpact & Hookup FeesCurrent Impact Fee$Current Connection Fee$Have you completed
a Capital Facilities Plan which meets the requirements of the Utah Impact Fee Act?Yes No (Please attach a copy of the Capital Facilities Plan)Current number of equivalent residential
connections Last year’s annual sewer user charge revenue $Last year’s annual, residential, user rate $Revenue Divided by User Rate (1)/(2)* *a rough estimate of residential equivalent
connectionsMajor Industries and approximate percent of workforce employed by eachPlease 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.)ProjectedProjectConstruction EstimatedDescriptionDateCostPlease provide
audited financial statements for the past two years and a copy of your current operating budget.Please provide a copy of your current sewer rate ordinance/resolution and user charge
system.Signature of person responsible for completion of this form*Signature of Authorized Representative*REMINDERYou must enclose the following:Facility Plan or other planning documents.Amortization
table for each outstanding debt.Audited Financial statements for the past 2 years plus this year's current budget.Current sewer rate ordinance/resolution and user charge system.Capital
Facilities Plan which meets the Utah Impact Fee Act.Signed Project Cost Acceptance Form (blank form attached to application form)