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COLOR ) RIVER BASIN SALINITY CONTROL T ')GRAM Cosl-S, ~ Assistance All Heation, Al!reement. and Pavn. ,Claim Da" Landowner SCD Contract, Page 5 of 6 IN ACCOUNT WITH THE 0312001 Delta Canal Company DELTASCD Soc. Sec.orTu: Idenl. No. Address I14-U4S3~1 477 1600 Road, Delta, Colorado 81416 I (we) the undersigned. do hereby request c:ost-share assistance to help defray the coat of installing the soil and water consen-1llion practices as listed below. It is undentood and egeed that: 1. UOh recelvlDlaoy cod-share (uad..lt will be aeeeuary for tbe IlIodowaer(s) to l1p the lllV"meal below relallnllo tbe mlllatenance 01 practices lastalled. 2. Pracdces must be pillaged aDd lastalled lu accordaace wUh tKbalc:a1 speciflcatloas of the Natural Resourcn CODSf",,,tioa Senrlu (NRCS). J. The rnpooslble technician must make prlordelenaloatioa tbat the practices are I,aslble 00 the site when they are to be I.stalled, that they are property planned aDd lastalled. aad thaI estlJDate. cl quaatitles are proper .ad reasonable. 04. It'1DlI 01 co.t lor wbleb nlmbunem.at Is lat", c1almtel an to b. luppanl'd by doel:lmeatatloD of pa)'JUellu made or dl:le to c:oatradon or olher _rurs. 5. Thll IIppUntioo will not bI dl'ted". undl approved by lb. SOU CooservatlOD DIstrict (SeD). Clalau for payment wtIJ Dot be .<<epltel more thaa aloe (9) mooths from IIII' date tllla application Is approy"; uolea. 1111 e:deulon Is p1llltl'd by the SCD. 6. Maximum nlmbunemeot will be IlmJIt(I to ttaelWrnot aareed UPOIlo oat to es:ceecl70% of the Ddual cost 10 tbe laodowuer; tile perce.tap or a"erage ~ts lpeclfll'd bllow; or, the amount oblipted by the SCD, .1I1~be".r Is the least. LOCATION OF PRACTICE: E 1/2. SEC 25. 30 . TWP 15 S. RNG, R96W. R95W . DELTA COUNTY FORUM 2000 FUNDS CONTRACT II 20??oo5 APPLICANT'S REQUEST PRACTICE UNITS PERFORMED AVG MAXIMUM COST- COST! ASSISTANCE SHARE RATE SHARE: EXTENT X YEAR PRACTICE UNIT EXTENT UNIT % $ YEAR EXTENT AVG _% SMALLEST ACT RATE 2003 587-STRCTR CINII FOR WATER 5 CONTROLL SA Concrde, Frrnd Cubic Yard 8,0 650,00 70 3,640,00 & Reinforced 58 Gate, Head Oia. htdt 30" 50,00 70 1,050,00 (15"X2) If you need more space, please attach a separate sheet. (4,690_00) TOTAL $ TOTAL $ LESS OTHER COST -SHARE ASSISTANCE $ Signature of landowner Of Authartzed Rep Date TOTAL AMOUNT LANDOWNER CLAIM $ Practices and Quantities requested are nceded and practical and 'Nill LANDOWNER(S) CERTIFICATION AND AGREEMENT: be planned in accordance with NRCS technical specifications. I certify that the items for VlIhich payment is claimed were furnished and that the charges are reaSOflable, proper, and correct, and no part of the claim has been paid. I further certify that I am the owner of the above described property and agree that if any or all of Signature of Technician Date above installed practices shall be removed, altered, or modified so as to lessen their effectiveness 'Nithout consent of the SCD for the -lifespan of the practice(st after the APPLICATION APPROVAL: date of receiving pa~ent, that portion of the claimed amount shall be refunded to the 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 fon;:e and to obtain such new owner's The SCD Board of Superviso" 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 agreement. Signature of Landowner(s) Date ~ature of seD Re resentative Date COMPLETION AND DOCUMENTATION CERTIFICATION: SOIL CONSERVATION DISTRICT CERTIFICATION: I hereby certify that the above claim has been reviO'Ned by me and I find it a proper claim against the Delta SeD Salinity Control Cost Share Program fund. Signature of Tec:hnician Date Authorized Signature Dato Sinnature of SCD ~~esentative Date Rev. 1015S