The information required by Env-Dw 1106.01(c) shall be as follows, submitted on or with “Form 3: Environmental Review”, NHDES-W-03-058, December 2020, available at https://onlineforms.nh.gov/?FormTag=NHDES-W-03-058:

1. (a) The water system’s name, mailing address, and PWS identifier;
2. (b) The short title for the project and the project number assigned by the department;
3. (c) The name and title or position of the contact for the project, together with an email address for the individual;

4. (d) An introductory paragraph that reads as follows, with the water system’s name filled in:

   “The [PWS Name] has applied for funds through the State of New Hampshire Department of Environmental Services Drinking Water State Revolving Loan Fund (DWSRF), in accordance with NH Code Admin. Rules Env-Dw 1100. This document fulfills the requirements of Env-Dw 1106.01(c) relative to providing information on the environmental review required by Env-Dw 1108.”

5. (e) An overview of the applicant’s water system and its customers, including the system’s source(s), capacity, number of service connections, and approximate population served;
6. (f) An explanation of the need and justification for the proposed project and a description and analysis of all reasonable alternatives, including a “no action” alternative, that the applicant considered during project planning;

7. (g) A description of the scope of the proposed project, including preconstruction work, and the following:

   1. (1) Maximum area of disturbance in square feet or acres, both temporary and permanent;
   2. (2) How many trees are planned to be removed or trimmed, if any, and when;
   3. (3) Any potential culvert installations on perennial streams or impacts to wetlands or surface waters; and
   4. (4) If replacement or removal of any structures is proposed, include the year the structure was built;
8. (h) The estimated cost of the overall project;
9. (i) How much the applicant has applied to borrow from the DWSRF;
10. (j) A list of each document that is available for public review that supplements the information provided pursuant to (e)-(g), above;
11. (k) A summary of potential environmental impacts arising from the proposed project relative to air emissions, noise, surface water, groundwater, wetlands, shoreland, floodplains, plants and wildlife;
12. (l) A summary of potential impacts on the community in terms of social and economic aspects, recreation, historic sites, and indirect impacts;
13. (m) The date the applicant’s governing body authorized funding for the project or is expected to authorize such funding and the amount authorized;
14. (n) A statement that the applicant agrees to publish a public notice to initiate a comment period on the report;
15. (o) An 8.5-inch by 11-inch copy of a topographic map at a scale that clearly identifies the location of the project and maximum extent of disturbance;
16. (p) Site plans with a scale bar indicating project location and maximum extent of disturbance;
17. (q) Any other supporting documentation such as shapefiles depicting the project limits of disturbance, consultations or correspondence with other natural resource agencies, environmental review documents prepared for other funding agencies, natural resource surveys or investigations, and planning documents;
18. (r) Photographs of the proposed project area and any existing structures to be replaced or renovated; and
19. (s) An affirmation, if true, that the applicant has permission from the landowner for the department to submit NH DNCR-natural heritage bureau “DataCheck” and division of historical resources “Request for Project Review” for the proposed project.

Source. (See Revision Note #1 and Revision Note #2 at chapter heading for Env-Dw 1100) #13160, eff 1-20-21