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COLOR' ) RIVER BASIN SALINITY CONTROL'> "GUAM Cost-S, ' ~ Assistance A. lication, Agreement, and Pam. Claim Da" Landowner SeD Contract, Pace 3 of 6 IN ACCOUNT WITH THE 03nOOI Delta Canal Company DELTASCD Soc. Sec. or Tax Ident. No. Address 84-12453?1 477 1600 Road, Delta, Colorado 81416 ((we) tho undersigned. do hereby request cost-share aaistancc to help defray lhecost ofWtalling the soil and water conservationpracticell as listed below. It ia undmtoodand agreed that L Before neel,,).._.)' cost-sban funds, It will bt DK"QIl')"for the landowtl.r(a) to lip tb. agnem.at below relotlag to the malateaaDU 01 practl", InstallN, 2. Practices must be plaDDed ....d lutallN In accordanc. with ftcbalcalspn:lfleatloas 01 tbe Natural Resouffes ConservatloD Sel'Ylce (NRCS). J. The ....poulble ItchDlellD on... make prior determlaalloD that the p",dlCM are reulbl. on tbe lite when lite)' are to bt la.talled,lhal the)' are properly plaDDed aad IMbUed. aad thai estimates or quantities are proper aad "8IOa8bl.. ... Items or CO$I for ..bleb nlmbun.m.alls later dahDrd an to M lupponrd by docllmratatlon 01 pa)'DIellu made or due to eontradors or other worbn. 5. Tbl. application will aot 1M dl'edlve until approved by the Soli Coa.senattoD District (SCD). Clalpu for Pll)"me.t will aol be ac<<pted more Iba. ala. (9) montht from tIw date ibis application Is appl"Oved; unm.. IUI .deaslon Is cranled by lb. SCD. 6. MaxllllDm "lmbu....m.at will be limited to the perunt alf"rd IlpoD, 1I0t 10 nceed 70% ofth. actual COIIt to tb.landown.r; lb. per<<ntage of anrage costs specified below; or,lb. alllounl obllgaled by tb. sen, whlcbev.r Is th.least. LOCATION OF PRACTICE: E 1/2, SEC 25.30, TWP 15 S. RNG, R96W. R95W. DELTA COUNTY FORUM 2000 FUNDS CONTRACT # 2000005 APPLICANT'S REQUEST PRACTICE UNITS PERFORMED AVG MAXIMUM COST - COSTI ASSISTANCE SHARE RATE SHARE: EXTENT X YEAR PRACTICE UNIT EXTENT UNIT % $ YEAR EXTENT AVG _% SMALLEST ACT RATE 2002 587-STRCTR CIN# FOR WATER 3 CONTROLL 3A Concrd.e. Frmd Cubic Yard 30,0 650,00 70 13,650,00 & Reinforced 3D Gate, Head Dia.Inch 66" 50,00 70 2.310,00 (I X 66") If you need more space, please attach a separate sheet. (15,960.(0) TOTAL $ TOTAL $ LESS OTHER COST -SHARE ASSISTANCE $ Signature 01 landowner or AuthOrized Rep Date TOTAL AMOUNT LANDOWNER CLAIM $ Practices and Quantities requested are needed and practical and will LANDOWNER(S) CERTIFICATION AND AGREEMENT: be planned in accordance with NRCS technical specifications. I certify that the Items for Yoohich payment is claimed 'Nere furnished and that the ch~uge$ are reasonable, proper, and correct, and no part of the claim has been paid. I further certify that I am the owner of the above doscribed property and agree that If any or all of SignahJreotTechnician o.ta above installed practices shall be removed, altered, or modified so as to leasen their effectiveness without consent of tho SCD for the "lifespan of the practice(sr after the date of receMf\9 payment, that portion of the claimed amount 'Shall be refunded to the APPLICATION APPROVAL: SCD. If title to this land is transferred to another party, it shall be my responsibility to advise the new owner that this agreement is in force and to obtain such new owner's The SeD Board of Supervisors approved the Applicant's Request and acceptance of the responsibilities herein. The attached plan/schedule of operations hereby obligate $ prepared by the NRCS is hereby made a part of this asrcement. Signature of landowner(s) Dat. S;;;nature of $CD Renresentative Date COMPLETION AND DOCUMENTATION CERTIFICATION: SOIL CONSERVATION DISTRICT CERTIFICATION: I hereby certify that the above claim has been rovielNed by me and I find it a proper claim against the Delta seD Salinity Control Cost Share Program fund. Signature of Technician Da'. Authorized Signature Dat. Sinnature of SeD R~resentative Date av. 10199