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3 <br /> Washington State Department of 2011 Drinking Water <br /> iHealth State Revolving Fund (DWSRF) <br /> Division of Environmental Health Application Form <br /> Office of Drinking Water <br /> Instructions <br /> • It is important that you read and understand the 2011 DWSRF Guidelines before you complete this application form. <br /> There have been several changes this year.You can download the guidelines at <br /> http://www.doftwa.goviehpldwtour_main_pages/dwsrf htm <br /> • Do not modify this form to change the font size, margins,or any other pre-set formatting. <br /> • If you want Affordability Bonus Points,you must submit documentation with your application of your water <br /> system's current average annual water rates(such as rates identified in the Water System Plan, Small Water <br /> System Management Program, or rates officially approved and adopted by the water system board or <br /> commission). <br /> • The application consists of the following: <br /> • This form, signed and dated <br /> • Affordability Bonus Points documentation(if you choose to apply for these points) <br /> • Project Review Sheet(EZ-1 Form) <br /> • EZ-2 Form (only applicable if the project consist of demolishing or modifying a structure) <br /> • Your metering exemption request letter, if applicable <br /> Applicant Information <br /> Applicant City of Everett Public Works Department <br /> Organization <br /> Water System City of Everett l PWSID#l24050l <br /> Name <br /> Address 3200 Cedar Street <br /> Everett State WA Zip Code ,98201 , County (Snohomish <br /> City <br /> Phone (425) 257-8800 E-mail sbridge@ci.everett.wa.us <br /> Contact E-mail sbridge@ci.everett.wa.us <br /> Shaun Bridge (425)257-8823 <br /> Contact Name Contact Phone <br /> Consulting Firm N/A <br /> N/A <br /> Consultant E-mail ,N/A <br /> Consultant Name Consultant Phone N/A <br /> 38th2nd <br /> Le•islative District Con a ressional District <br /> Project Information <br /> Project Name: Portal#3 Modifications at Chaplain Reservoir <br /> Project Description: <br /> A 54"concrete cylinder pipe carries potable water from the City of Everett Water Filtration Plant to Portal#3 which is the <br /> entrance to a tunnel leading to the transmission lines. As the pipe enters the portal an air gap is created in the system <br /> and the water free falls about 25 feet down to the entrance to the tunnel. This project will address the risk of <br /> contamination by providing for the installation of a stainless steel pipe connecting the 54" pipe and the tunnel.The <br /> stainless pipe will then be encased in concrete.This sleeve is required by the Department of Health to provide a positive <br /> barrier between the potable water inside the portal and untreated lake water. In addition, the project will provide for <br /> seismic upgrades to increase the safety factor during a 2500-year earthquake event. A brick structure which is no longer <br /> needed will be removed from the top of the portal. <br /> DOH Form 331-201(Rev.10110) <br /> 41 <br />