HomeMy WebLinkAboutWPO201400071 Application 2014-11-170
Virginia Stormwater Management Program (VSMP)
Application for Albemarle County, ,
Project Name: Di(_1 ..f a1� V l6�tt.tlty � C;C; lZ 6"1 t)Il o") ncl
(The name should be the scmie a if appears on plans) (A u 'l c k,() "!�V' ) r. "1,{.
Is this an amendment to an approved plan? Yes ❑ No l
Is this a revision or resubmission for review? Yes)A No ❑
County File Number: 1Aj F (;1 ' U I L1 0()0 7 i (to be provided by the Counly for neiv applications)
The following are required elements of'new applications L6-om code section 17-401]. For revisions or
amendments, please indicate which items are being amended Signaillres must be provided for any
submission.
C+ 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.
Tax Map & Parcel Print Name of Property Owner "Ignatu wner; Date
Tax Map & Parcel Print Name of Property Owner
Tax Map & Parcel Print Name of Property Owner
Tax Map & Parcel Print Name of Property Owner
Contact Information for the Owner(s) to receive correspondence:
Print Name D(t'y C: Pw-u " i-lay-1 e,u.-k-)
Signature of Owner Date
Signature of Owner Date
Signature of Owner Date
Address CJ L�t_a t'�t �1 N' lit"" t > i- r f 14� t 1� `� eJ l l 00
City t..a .' �(� State Zip '7'?e'
Daytime Phone ZD Z) 1.1 i E-mail C:t l t ' (�'- Ci (C (I t i 1 U i i i L( (2 t (ll ir✓i
7/1/14, Revised: 7/10/14 Page 1 of
M
® B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed 60, 5 AC -
Acres to be
disturbed
Total Fee
Fee Due with this
Application
Fee with Transfer or
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
Mitigation Plan; $150
i C. Registration Statement on the official DEQ form.
Rf D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
d E. Stormwater Management Plan satisfying the requirements of code section 17-403.
lA F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
M G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405.
❑ 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.
❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the
requirements of code section l 7-422.
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 ili LeUoe-i,eV
Address M U igtl C C t 1 C, (2 CA .
City CV11,t-00-+tSvtlle State VA Zip 0 901Z
Daytime Phone Oq314) 1�17 7 - O ZU 5 E-mail l-td be-4 -t--Y- L r(,j j0-b,-i jh , (.o,-, l
*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 # Ck# By:
7/l/14, Revised: 7/10/14 Page 2 of