HomeMy WebLinkAboutWPO200800037 Application WPO VSMP 2018-09-17 •
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Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
Project Name: AV YsV/LLE f311J),V Ecf f/bt
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes O No I ]
Is this a revision orfresubmissioafor review? YesK No ❑
County File Number: (WO 2.0a80 003 7 (to be provided by the County for new applications)
The following are required elements of new applications [from code section 17-401]. For revisions or
amendments,please indicate which items are being amended. Signatures must be provided for any
submission.
❑ A. Signature of the Property Owner for each parcel: (Required with every submission or revision, NOT
TO BE SIGNED BY AN AGENT OR CONSULTANT)
By signing this application as the owner, t hereby certify that all requirements of these plans and permits will be
complied with,and I have the authority to authorize the land disturbing activities and development on the subject
property. I hereby grant the County of Albemarle the right to e• pon the property as required to ensure
compliance with the approved plans and permits.
3I-z14iJ& Ksi-e/c /� sVi.7/a-
Tax Map&Parcel Print Name of Property Owner Signature of Owner Date
Tax Map&Parcel Print Name of Property Owner Signature of Owner Date
Tax Map&Parcel Print Name of Property Owner Signature of Owner Date
Tax Map&Parcel Print Name of Property Owner Signature of Owner Date
• Contact Information for the Owner(s)to receive correspondence:
Print Name /I401,/dlpr4 /•7LI7NtVI/1/( 6-11403
Address r ' "0111t1 COZCLE Sit ZOa
City CV)01t or715Lit.tie State v/n Zip 2ZM0I
Daytime Phone(WY) 651_ 0114 E-mai l It John,wilt CCM
7/1/14,Revised: 7/10/14, 1/7/14 Page 1 of 2
❑ B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed
Acres to be Total Fee Fee Due with this Fee with Transfer or
disturbed Application modification of permit
Less than 1 $290 $145 $20
1 and less than 5 $2,700 $1,350 $200
5 and less than 10 .$3,400 $1,700 $250
10 and less than 50 $4,500 $2,250 $300
50 and less than 100 $6,100 $3,050 $450
100 and more $9,600 $4,800 $700
For(minor)amendments to an approved plan; $200 per review
Variances;$150(per request)
Mitigation Plan; $150
❑ C. Registration Statement on the official DEQ form.
❑ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
❑ E. Stormwater Management Plan satisfying the requirements of code section 17-403.
❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405.
O H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of
stream buffers.
❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408.
O J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the
requirements of code section 17-422.
Provide 2 copies of all plans and any supporting documents. Professional seals must have original
signatures.
Additional information if not provided on plans and documents:
Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent)
Print Name
Address
City State Zip
Daytime Phone( ) E-mail
*When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months
from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's
signatures will not be considered valid.
FOR OFFICE USE ONLY WPO#
Fee Amount$ Date Paid By who? Receipt# COI By:
7/1/14,Revised:7/10/14, 1/7/14 Page 2 of2
411. COUNTY OF ALBEMARLE
?1 =_.
Department of Community Development
u 1BIW:74' 401 McIntire Road
y` A Charlottesville,Virginia 22902
VSMP Application Completeness Check
Project Title:
File Number:
Date:
Reviewer:
Your application has been checked for completeness per section 17-409 of the County Code. All
items must be received and correct for the application to be deemed complete.
•d This application is complete and plan review has begun
❑ This application is not complete. Please provide the missing items
checked below.
Received Correct
Y N aijsz, Y N N/A
6( 0 Completed application U• woctS ❑ ❑ 0
f� ❑ Signatures of the Property Owners for each parcel affected 3(-21 A ❑ ❑ ❑
id 0 Correct Fees Paid 3►'-z l D? ❑ ❑ 0
pc 0 Registration Statement on the official DEQ form, with correct LDA ❑ ❑ ❑
❑ Erosion and Sediment Control Plan satisfying the requirements
of code section 17-402. ❑ 0 0
11' ❑ Stormwater Management Plan satisfying the requirements of code
section 17-403. 0 ❑ 0
d0 Pollution Prevention Plan satisfying the requirements of code
/ section 17-404. The EPA template should be used. 0 CI
P ❑ Stormwater Pollution Prevention Plan satisfying the requirements
of code section 17-405. The EPA template should be used. ❑ ❑ 0
❑ Ej Mitigation Plan satisfying the requirements of code section
17-406 for any proposed disturbance of stream buffers. ❑ ❑ E
❑ Requested Variations or Exceptions as provided in code sections
17-407 and 408, if applicable. (SSF,MMT,etc) ❑ ❑ ❑
❑ Construction Record Drawings (as-builts) for any existing facilities
in the proposal satisfying the requirements of code section 17-422. ❑ 0 ❑
Comments:
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