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PNUM 05 < � <br /> trI'� SJRWMD office use <br /> ST. JOHNS RIVER WATER MANAGEMENT DISTRICT <br /> ALTERNATIVE WATER SUPPLY CONSTRUCTION COST-SHARING PROGRAM <br /> APPLICATION FORM <br /> FY 2004.2005 <br /> Submission deadline: Applications must be received by the St. Johns River Water Management <br /> District (SJRWMD) or dated by the U.S. Postal Service or a commercial carrier no later than Friday, <br /> August 6, 2004 . Submit three copies of this form and all supporting materials to Elizabeth Thomas, <br /> c/ o Cheryl Keel, St. Johns River Water Management District, 4049 Reid Street, Palatka, FL 32177. For <br /> application assistance, contact Elizabeth Thomas at (407) 659-4868 or ethomas@sjnvmd. c m. You may <br /> add up to one additional page of supporting material for any answer that needs further explanation. <br /> Applications that are substantially incomplete or are not completed according to insiTuctions will <br /> be disqualified. Excess materials will not be considered. Read and follow instructions. Selected <br /> evaluation criteria accompany questions pertaining to them in the application. Complete evaluation <br /> criteria are provided in the separate instruction document. <br /> Type or print clearly the requested information in the spaces provided. <br /> Title of project Grand Harbor Mosquito Impoundment/ Mangirove Restoration Project <br /> A. Applicant Information <br /> 1 . Name of applicant/ Title Indian River Cglm Utilities _ <br /> (may be utility, local government, agency, company, individual, or other) <br /> 2. Name, address, email address, and phone numbers of project manager or contact person. <br /> SJRWMD will send correspondence concerning this application ONLY to this person. <br /> Name/ Title Michael C. Hotchkiss P.E. Capital Projects Manager <br /> Email address mhotchkiss@irc ov.com <br /> Mailing address Indian River County Utilities 1840 25th Street <br /> City and zip code Vero Beach FL 32960 <br /> Phone M2 567-8000, ext. 1821 Fax (772) 770-5143 <br /> 3. Name, address, and phone numbers of person with authority to enter into a contractual <br /> agreement, if other than project manager or contact person. <br /> If same as 2 above, check box. ❑ <br /> Name/ Title Caroline D. Ginn Chairman <br /> Email address cprLmn@ircgg.v .com <br /> Mailing address Indian River ComM, 1840 25thStreet <br /> City and zip code Vero Beach FL 32960 <br /> Phone M2a 567-8000, ext. 1490 Fax (772) 770-5334 <br /> A-1 <br />