NON-POINT SOURCE POLLUTION CONTROL COST-SHARE PROGRAM APPLICATION FORM

Initial fiscal year 2009 sign-up period: March 1 to March 31, 2008

*To be eligible to replace a failed septic system you must have a letter from the county sanitarian (785-826-6604) stating system is failing and meet at least one of the location criteria listed in the next section. Decommissioning Wells (well plugging) must be completed according to the state specifications that will be provided to the landowner.   Construction on any project may not begin until application has been approved. If you receive cost-share funds exceeding $600.00 you will receive a 1099 from the State of Kansas. Falsified information results in repayment of cost-share funds.   Any applications returned with coffee &/or donut stains must be accompanied by a cup of coffee &/or donut (preferably fresh). ================================================================================

On-Site Wastewater (Septic) System Eligibility Worksheet

If the answer to any one of the following questions related to the location of a failing on-site wastewater system is “yes”, the system meets the location criteria and is eligible for cost-share funds. Circle all that apply. Failing on-site waste system is located:   A. 500 feet or less from a perennial stream                                                           B. within a shallow aquifer area                                                             C. within a 2 mile radius of a public water supply well Failing on-site waste system is located at a home site where a well is the primary water source for human use AND one or all of the following apply:                                                             A. Current failing system is a rat hole, cesspool or seepage pit                                                         B. Current failing system is within 100ft of domestic well                                                         C. Current failing system is up gradient of domestic well and is within                                                             400 ft. of the domestic well.                                                         D. The domestic water well has tested positive for fecal coliform                                                             bacteria or has elevated nitrate levels (over 10 ppm) and the failing                                                             system is determined by the local sanitarian to be a possible source                                                             of the contamination. If you did not answer yes to at least one of the above questions the failing wastewater (septic) system is NOT eligible for cost-share funds. =============================================================================

TRUST NAME:__________________________________________________________     OR OWNER NAME:_________________________________________________________ MAILING ADDRESS:_____________________________________________________ CITY:________________________________ ZIP:______________________________ OWNER SOCIAL SERCURITY # OR TRUST EIN #____________________________ PHONE:________________________________________________________________ LEGAL DESCRIPTION: NW NE SW SE 1/4 OF _____-______-_____TRACT#______

PAGE TWO Please answer each question for the project you wish to complete

============================== Failed septic system: Type of proposed system Size of proposed system Will any components of old system be used (tank, pipe) ============================== Animal waste facility: Type of proposed system  Size of proposed system Is this in conjunction with another program? Yes / No ============================== Decommissioning abandoned well: Estimated depth      #feet ==============================

=================================== Fertilizer containment structure: Is above ground storage for 2,000 gallons or less? Yes/ No =================================== Riparian area protection & enhancement: Fencing                          #feet Filter strips                    #acres #cubic yards of dirt work      # acres of seeding               Riparian area buffer       #acres Trees                            #trees Weed barrier fabric          #feet ===================================

========================================================================= This form is an application for cost-share assistance.  I understand completing this form does not guarantee approval for funds. Landowner’s Signature: X________________________________________