HomeMy WebLinkAboutSDP201500020 Application 2016-02-01 Virginia Stormwater Management Program(VSMP) ':,
Application for Albemarle County
Project Name: SA k.wooei Terra Q.
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes 0 No lU
Is this a revision or resubmission for review? Yes 50 No 0
County File Number: SD P Z o(S o 00 2 a (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,I 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 enter upon the property as required to ensure
compliance with the approved plans and permits.
TM61 P. ioA 6'.1\1 qie /Pe- z/Ol /14,
Tax Map&Parcel Print Name of Property Owner Signature of Owner Date
.1.M 61, P IQA2 -V"" (3.fl site 2401 116
Tax Map&Parcel Print Name of Property Owner Si 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 r i c... L1 is()
i
Address .0, V O X l�
city ram-L(js v i l I e state U i zip zzl 3-4
Daytime Phone(/ 9 ) 53/-7/i`7 E-mail �—�'(f;s Pie @_ v-,5 1. C 0 t.-1
•
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• B. All Fees [Code section 17-208]
For new or modified plans;Total acres proposed to be disturbed I, Li AL
Acres to be Total Fee Fee Due with this Fee with Transfer or
disturbed Application modification of permit
Less than 1 $290 I $145 $20
I 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 S4,800 $700
For(minor)amendments to an approved plan;$200 per review
Variances;$150(per request)
vlitigation Plan;S150
❑ 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.
❑ 1-l. 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.
❑ 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 correspondencee (usually the plan preparer,consultant or agent)
Print Name US --•• J �tivt,A0
Address Z 0 k i�u t� S 1Y`e e %
City 1 .&*)4 lO t 5 Ale State v q Zip 22.7 0 2.
o
y3 21-7— $I`lb � r. i►nc-i^ rcw
Daytime Phone( �) E-mail J U S�-��� � �Q—e ee
*\Vhen applications and plans arc reviewed,but not approved,and a response to comments is not received within 6 months
from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's
signatures will not be considered valid.
FOR OFFICE USE ONLY %PO#
`£ who?.5163E143 A/1�0.57R ec.1a45tit A /Oa Ckt.''3 a3')^ity_1iC .'`�/
Pee Amount$ �3SU Date 1 a,dv?'�'/� Hy { Y�
Co 9_6(.4 Ls_
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