Application Date:	Application Number:
(VDOF Headquarters Office Use Only)
Application to:	Install New Dry Fire Hydrant	Repair Existing Dry Fire Hydrant
SECTION 1 – Applicant Information
Fire Department Name:
Fire Dept. ID Number (5 digit number):	Federal ID Number (9 digit number):
Mailing Address:
City:	State:	Zip:
County/City/Town:
Project Manager:	Title:
Phone:	Fire Station:	Work:
Cell Phone:	Home:
E-mail:
SECTION 2 – Site Information
County of Hydrant Site:	Site Location Priority:	1	2	3
Location of Proposed Dry Fire Hydrant:
Subdivision (if applicable):
Street Address:	Route Number:
Cross Street:	Route Number:
Type of Water Source:	Pond	Lake	River	Stream/Creek	Tidal Influence (if applicable)
Distance from Dry Fire Hydrant to the Public Road:
Travel Distance from Fire Station to Dry Fire Hydrant:
Within Two (2) Square Miles:	Number of Homes:	Number of Other Structures:
City:	State:	Zip:
Attach the following to your application:
County map section indicating the general location of proposed hydrant site(s) Sketch map indicating the specific location of proposed hydrant site(s) Printed photograph of proposed hydrant site(s) (taken to record desired hydrant head location down to water source)
SECTION 3 – Repair Information	(Only required for Repair applications)
Is the landowner the same as the landowner when it was installed?	Yes	No
If no, Section 5 Landowner Authorization must be completed.
If yes, Section 5 Landowner Authorization does not need to be completed.
Dry Fire Hydrant Problem:
Describe Repair Needed:

SECTION 4 – Applicant Agreement
The fire department named above hereby makes application for a Dry Fire Hydrant Grant, administered jointly by the Virginia Department of Forestry and the Department of Fire Programs. The fire department agrees to comply with all requirements of the grant program, including the following regulations, policies, guidelines and requirements, both federal and state, as they apply to this application and grant, should the grant be made to the fire department: The fire department possesses legal authority to apply for the grant; that a resolution, motion or similar action has been duly adopted or passed as an official act of the applicant’s governing body, authorizing the filing of the application, including all understandings and assurances contained therein, and directing and authorizing the person identified as the official representative of the applicant to act in connection with the application and to provide such additional information as may be required. It will ensure that this grant will be used in compliance with the Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and in accordance with Title VI of that Act, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the applicant receives the grant assistance and will immediately take any measure necessary to effectuate this agreement. It will comply with Title VI of the Civil Rights Act of 1964 (42 USC 2000d) prohibiting employment discrimination where 1) the primary purpose of a grant is to provide employment or 2) discriminatory employment practices will result in unequal treatment of persons who are or should be benefiting from the grant-aided activity. It will establish safeguards to prohibit employees from using their positions for a purpose that is or gives the appearance of being motivated by a desire for private gain for themselves or others, particularly those with whom they have family, business or other ties. It will give the sponsoring agency or authorized representative access to and the right to examine all records, books, papers or documents related to the grant. It will comply with all requirements imposed by the grantee’s sponsoring agency concerning special requirements of State and Federal law; program requirements, and other administrative requirements. It will comply with Section 504 of the Rehabilitation Act of 1973 as amended (29 USC 794) and all regulations, guidelines and interpretations issued pursuant thereto. It provides that no otherwise qualified handicapped individual shall solely by reason of his handicap, be excluded from the participation in, be denied the benefits of, or subject to discrimination under any program or activity receiving federal financial assistance. Periodic maintenance of the site and hydrant should be performed regularly. At a minimum, the dry fire hydrant should be back flushed once each six months. Although gravity flow is recommended, no more than 20 psi shall be applied to the hydrant during the back flush process or the fire department will be liable for any related costs of repair. This is the Fire Departments responsibility to maintain the hydrant. The fire department is responsible for paying all expenses that are not covered under a standard installation. Due to the varied nature of water sources found throughout the Commonwealth of Virginia it may be necessary, in some applications, to utilize dry fire hydrant components not covered under the grant to insure a dependable drafting source year around. The fire department is responsible for ensuring that proposed dry fire hydrant sites have dependable all-weather access. For sites found not to have adequate all-weather access at the time of the initial site visit, the fire department will provide a letter of assurance to the contractor, for inclusion in the grant file, stating that arrangements have been made to provide said access. This letter will need to be provided before installation of the hydrant can proceed. All applicable federal, state, and/or local permits have been properly obtained and/or waived, and supporting documentation thereof has been included along with this grant application. The fire department is responsible for advising the landowner of the installation procedures and utilization of the dry fire hydrant.
We understand and accept the above agreement, specifications and requirements. Any violation of the related policy and procedures within the grant process will void this agreement.
Fire Department Authorized Representative Name (Print)	Authorized Representative Title
Fire Department Authorized Representative Signature	Date
SECTION 5 – Landowner Authorization	(Not required for Repair applications if landowner is the same as when installed)
Landowner Name:
Landowner Address:
City:	State:	Zip:
E-mail:	Phone:
I hereby grant permission to
Name of Fire Department
to install a dry fire hydrant at
Proposed Dry Fire Hydrant Location
for the purposes of providing water to extinguish fires in my community and for other uses with my permission.
The Fire Department may use or test the dry fire hydrant at any time they deem necessary to maintain continuity of hydrant operations. At a minimum, testing of the dry fire hydrant should occur once every six months. Following the installation of the dry fire hydrant by the state-approved contractor, the property will be returned to a field grade quality as provided for by the governing state contract. This means the ground will be as smooth as possible while utilizing a backhoe, hand raking of disturbed areas, and application of grass seed and straw. In addition, hardtop surfaces, such as roadways and drives, will be hand swept. Depending on weather conditions, hand raking may not eliminate all clumps of soil. Note: Any additional reclamation work not stated above and required of the installing agency by the property owner and or fire department will be billed to the requesting party at the rate of time and materials. The installation and operation of the dry fire hydrant has been fully explained and I agree to all parts. Permission is hereby granted to come upon my property to install, maintain, and operate said hydrant. To revoke this permission, I will give thirty (30 days) written notice to the above-mentioned fire department. In the event the permission is revoked, all parts of the installation will be removed at the expense of the above fire department.
Landowner Name (Print)	Landowner Signature	Date
SECTION 6 – Application Package
Attach the following to your application:
County map section indicating the general location of proposed hydrant site(s)
Sketch map indicating the specific location of proposed hydrant site(s)
Printed photograph of proposed hydrant site(s) (taken to record desired hydrant head location down to water source)
SECTION 7 – VDOF Area Staff Approval
I certify that there is a need for this dry fire hydrant and approve of the location chosen for installation.
Comments:
VDOF Area Employee Name (Print)	VDOF Area Employee Signature	Date
SECTION 8 – VDOF Approval
All Attachments Included:	Yes	No	Approved	Tentatively Approved	Denied
Comments:
Resource Protection Program Manager Name (Print)	Resource Protection Program Manager Signature	Date