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6 <br /> is your project located In a distressed county?(see Appendix C of the guidelines) ❑YES ®NO <br /> Is this a water system restructuring/consolidation project that will result in a ❑ YES ®NO <br /> change in ownership? <br /> Do you have a current DOH approved Water System Plan or Small Water System <br /> Management Program that includes the proposed project? ®YES 0 NO <br /> Is your engineering and design work completed? 0 YES 0 NO <br /> Have you submitted the required construction documents and project report to your ❑YES ❑NO <br /> DOH regional office? (You must coordinate with your DOH Regional Office to determine <br /> if these documents are required for your project) <br /> Have you secured any required easements and right-of-way? ®YES 0 NO <br /> • <br /> Do you have sufficient water rights for your project? ®YES 0 NO <br /> Do you have source meters on all existing water sources? m YES 0 NO <br /> Does the water system have service meters on all existing services?(If no,your project ❑YES ®NO <br /> must include service meter installation—see guidelines for more information). <br /> Does the project include service meter installation? 0 YES ®NO <br /> Are you asking for a service meter exemption?(see guidelines for eligibility) If so, ®YES ❑NO <br /> attach metering exemption request letter to application. <br /> Will you be using any other funding sources for your project?If yes,please list funding ®YES 0 NO <br /> sources and amounts: <br /> Funding Source:DWSRF Loan Amount: $3,000,000 <br /> Fundin Source:Local Funds Amount $3,880,000 <br /> Funding Source: I Amount <br /> Do you want to be considered for Restructuring Bonus Points?(see guidelines) <br /> _If yes,list the names and PWSID#'s for each system being taken over and restructured. 0 YES 0 NO <br /> Name: PWSID#_ <br /> Name f PWSID#: <br /> Name: PWSID#: <br /> Name: PWSID#: <br /> Name: PWSID#: <br /> DOH Form 331-201(Rev.01/10) 4 <br /> 22 <br />