STATE OF DELAWARE DRINKING WATER STATE REVOLVING FUND Source Water Protection Loan Fund LAND ACQUISTION AND CONSERVATION EASEMENTS APPLICATION CHECKLIST ALL APPLICANTS MUST INCLUDE THE FOLLOWING: - Two copies of the loan application form; - The original and two (2) copies of the site appraisal; - A Contract of Sale/ or Conservation Easement Agreement signed by the applicant and the site owner(s); - A completed Seller’s Disclosure Form provided in the loan application package and; - Two maps indicating the proposed site’s proximity with respect to the delineated source water protection area THE FOLLOWING ITEMS ARE DEPENDENT UPON THE TYPE OF WATER SYSTEM YOU ARE APPLYING UNDER: I. Publicly owned (municipal) drinking water providers must include two copies of each of the following - Audited financial statements for the three most recent fiscal years; - Current year budget; - Town Charter; - Most recent bond rating, if available; - Current and proposed user rates II. Corporate or privately owned systems shall provide two copies of each of the following with the application package: - Most recent three years audited financial statements; - Current year unaudited financial statements; - Articles of Incorporation; - State of Delaware business license; - Listing of corporate officers - In addition, sole proprietorship and Chapter S corporations must include signed IRS and State of Delaware tax filings for the last three years - Evidence of the Internal Revenue Service tax exempt status of a nonprofit noncommunity entity must be included with the organizations application DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Office of Drinking Water STATE OF DELAWARE DRINKING WATER STATE REVOLVING FUND SOURCE WATER PROTECTION FUND APPLICATION Delaware Health and Social Services Division of Public Health Office of Drinking Water 655 Bay Road, Suite 203 Dover, DE 19901 Phone (302) 741-8585 Fax (302) 741-8631 Type of Loan Applying for (check one): _____ Land Acquisition _____ Conservation Easement Section I- Applicant Information (please print or type) Applicant’s Name and Address: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Phone #_________________________Fax #____________________________ Primary Contact Person (Authorized Official): Name:____________________________________________________________ Address:_________________________________________________________ Phone #_________________________Fax #____________________________ Project Contact: Name:___________________________Phone #__________________________ Name and Location of Public Water System (site): ________________________________________________________________ ________________________________________________________________ Type of Public Water System (check one) _____ Public-owned community _____ Investor-owned community _____ Privately-owned community _____ Nonprofit noncommunity _____ Other: please explain:___________________________________ Section II- System Information Source Type (check one): _____ Surface Water _____ Ground Water, Unconfined Aquifer _____ Ground Water, Confined Aquifer _____ Ground Water, Mixed Sources _____ Ground Water, Under Direct Influence of Surface Water Site Size (Ratio of acreage to Source Water Protection Area Acreage): ______________Greater than 50% ______________30% to 49% ______________20% to 29% ______________10% to 19% ______________5% to 9% ______________Less than 5% Site Information Name of current owner:___________________________________________________ Tax Parcel Number:______________________________________________________ Is the property located in the 100-year floodplain? Y N Percentage of Impermeable Surface on the property: _____ % Approximate distance(s) and direction(s) to nearest stream(s): ______________________________________________________________________ ______________________________________________________________________ Briefly explain how the land acquisitions/easement will directly promote public health protection and/or compliance with national drinking water regulations. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Section III- Funding Information Appraised Value of Site: $_______________________________ Name of Person who performed the appraisal: ________________________________ Date of the submitted appraisal: ________________________________ DWSRF Loan Assistance Required: ________________________________ Site Acquisitions Cost, only ________________________________ Site Acquisitions Cost and Closing Cost ________________________________ Type of Security Applicant anticipates providing to secure the Loan: Pledge of Revenue of the Water System ________________________________ Pledge of Revenue of Water & Sewer System ________________________________ General Obligation Bond ________________________________ Senior Debt Obligation ________________________________ Mortgage/Lien on the serviced property ________________________________ Other: ________________________________ ________________________________ Service Area Connections: Metered connections: ________________________________ Unmetered connections: ________________________________ Total connections: ________________________________ Current User Rates (Monthly) Last Adjusted (Year) Previous Rate Metered connections: _______ ________________ ___________ Service connections: _______ ________________ ___________ Submit the rate schedule, if applicable Describe Rate setting procedures for the system: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Service Area Population: ________________________________ Median Household Income of Service Area: ________________________________ Data Source and date of MHI: ________________________________ Applicant’s Certification: I certify the information that is contained in this application and on any attachments to this application is true and correct to the best of my knowledge. I certify that I am legally authorized to sign, date and submit this information on behalf of the applicant. The undersigned also agrees to clarify or supplement information pertaining to this application upon request. Name and Title:_________________________________________________________ Address:_______________________________________________________________ Signature:______________________________________Date:___________________ Appendix I Land Owner Site Disclosure Circle the best answer (Y = Yes, N = No, U = Uncertain) 1. Has this property, at any time in the last 15 years, been declared a Superfund site by EPA or has it been investigated through the DNREC Site Investigations and Remediation Branch? Y N U 2. Is there an Underground Storage Tank or a Leaking Underground Storage Tank located on the property? Y N U If so, please provide the following: Regulated Facility? Y N Facility Name:_______________________ Facility ID No.:_______________ 3. Is there a landfill or dumpsite on the property? Y N U 4. Is there a National Pollutant Discharge Elimination System (NPDES) permit associated with this property? Y N U If yes, please provide NPDES Permit #_________________________________ 5. Are there any tire piles located on this property? Y N U 6. Has this property ever been used as a Hazardous Waste Generator or a Transportation, Storage, or Disposal (TSD) Facility? Y N U If yes, please provide the Facility Permit Number (if applicable):______________ 7. Is this property, or has this property been, listed in the Delaware Toxic Release Inventory? Y N U 8. Is this property, or has this property ever been a salvage yard? Y N U If yes, please provide the DNREC Stormwater permit Number:_______________ 9. Is this property, or has this property ever been a pesticide loading, mixing, and storage facility? Y N U 10. Is there, or has there been, a domestic septic system on the property? Y N U If yes, please provide the septic permit # (if applicable):___________________ 11. Is there, or has there been, a large (greater than 2500 gallons daily) on-site septic system associated with this property? Y N U If yes, please provide the septic permit Number (if applicable):_______________ 12. Is there, or has there ever been, a waste water spray irrigation facility associated with this property? Y N U If yes, please provide the Facility Permit Number (if applicable):______________ 13. Is there, or has there ever been any land application of waste sludge associated with this property? Y N U If yes, please provide the name of the Waste Hauler(s):____________________ 14. Is there, or has there ever been, a confined animal feed operation associated with the property? Y N U If yes, does this property have a Nutrient Management Plan? 15. Is there, or has there been, a combined sewer overflow associated with the property? Y N U 16. Are there any existing or known dredge spoils on the property? Y N U 17. Is the property associated with a golf course? Y N U 18. Are there any other potential sources of contamination located on the property? Y N U If yes, please provide more detail: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Source Water Protection Loan Fund II. Permitted/ Non-Permitted Uses The borrower is prohibited from the following activities on the acquired land or easement: - New Commercial and Industrial Activity - Storage of chemicals - Extractive use/ mining for soil, sand & gravel, rock, or other materials - Application of fertilizers or pesticides - Application, disposal, or dumping discharge of wastes, manure, refuse, rubble, or wastewater - Alteration of any designated or delineated wetlands - Livestock grazing or raising of livestock or poultry in confined areas - Hiking, biking, or equestrian activities in areas where the slope of the land exceeds 15% - Clear cutting of woodlands - Road construction or paving - Motorized vehicle use of any kind, except for emergencies, or repairs to the source structure, or protecting the supply - Building of facilities or other structures on the property after the signing of the agreement, unless approved by the Water Supply Section of the Delaware Department of Natural Resources and Environmental Control (DNREC). - Any activity, as deemed by DNREC that will endanger the safety of the water supply source. The following activities and uses are permitted by DNREC on all easements and/or acquired lands: - Planting of trees or vegetation, except as prohibited - Public education activities (ie. Guided tours, workshops, etc.) - Improvement, repairs, or replacement of existing water system infrastructure such as surface water intakes, pipelines, manholes, valves, pump stations, etc. All work must be done with approved plans and specifications, and approved by DNREC before starting - Installation of fences and/ or barricades around water supply sources for protection - Maintenance of existing trails, fire roads, or forestry roads - Creation of open space, which may include low impact recreational activities, biking, or hiking in areas where these activities are not prohibited by steep slopes 1 APPRAISER LIST Appraisal Associates, Inc. 2101 N. Tatnall Street Wilmington, DE 19802-4109 302-652-0710 302-652-1098 fax Robert McKennon David J. Borek 138 Glade Circle West Rehoboth Beach, DE 19971 302-226-1990 302-226-2004 fax Brown Appraisal Company 3213 Heathwood Road P.O. Box 7848 Wilmington, DE 19803 302-477-0098 302-477-1799 fax Charles Brown Carmean Appraisal Group P.O. Box 441 Georgetown, DE 19947 302-628-4500 302-542-2053 Harold Carmean Cornerstone Appraisal Group, Inc. 101 Briar Lane Newark, DE 302-368-9020 302-368-9102 fax Jeffrey Merrick Dover Consulting Services, Inc. 555 E. Loockerman Street Dover, DE 19901 302-736-1365 302-736-2715 fax Charles Darrell Dan Enterline Real Estate 42 South State Street Dover, DE 19904 302-674-5544 302-674-5702 fax Greystone Realty Advisors, Inc. One Riverwalk Centre 110 S. Poplar Street Wilmington, DE 19801 302-777-2300 302-777-2390 fax David Wilk G. M. Records, Inc. 46 South State Street P.O. Box 1979 Dover, DE 19903 302-736-0210 302-678-3504 fax Jerry Records Carl Kaplan Tidewater Properties 24488 Sussex Highway, Suite 3 Seaford, DE 19973 302-629-4635 302-629-4913 fax Laurence P. Moynihan LandMark Associates 9 Bradford Lane Lewes, DE 19958 302-645-7070 302-645-9493 FAX 302-542-7400 Cell Glenn T. Piper Francis E.B. McCann, Jr. & Associates Real Estate Appraisal Service Box 1161 Newark, Delaware 19715-1161 302-368-1111 302-528-1181 cell 302-266-7048 fax Frackan@aol.com Francis McCann 1/08 - 1 - - 1 - Doc. # 35-05-20/08/02/40