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6 <br /> Project Scope of Work Loan Request(Costs) <br /> (list what you will do,along with schedule) <br /> What When What How much <br /> - Engineering Report(Preliminary <br /> En•ineerin• <br /> Environmental/Cultural Review <br /> - Land/Ri•ht-of-Wa Ac•uisition <br /> . Permits -- <br /> Public Involvement/Information <br /> Design Engineering 7/10 Bid Documents Desi•n En•ineerin• 1,220,000 <br /> Construction Contract 6/12 Construction 5,660,000 <br /> DOH Review/A••royal Fees <br /> Contin•enc <br /> Other Fees: Sales or Use Taxes <br /> Service Meters(Purchase and <br /> Installation <br /> Audit Costs <br /> Local Funds Other describe : -3,880,000 <br /> Other describe : <br /> Other describe : <br /> Other describe : <br /> Other describe : ■_ <br /> DWSRF Funding Request TOTAL $3,000,000 <br /> Loan Fee(1%of the Total) $30,000.00 <br /> TOTAL FUNDING REQUEST(add the two lines above) $3,030,000 <br /> Additional information about your project(please refer to the guidelines). This information isnot scored.It is <br /> Applicant requests consideration for loan forgiveness or a lower interest rate(see <br /> guidelines). You must be prepared to provide documentation that your community is <br /> low-moderate income using either Census 2000 data or an independently-conducted 0 YES ®NO <br /> income surve . <br /> Applicant requests retroactive funding(see guidelines for eligibility requirements). 0 YES ®NO <br /> DOH Form 331-201(Rev.01/10) 3 <br /> 21 <br />