HomeMy WebLinkAboutWPO201400071 Other 2014-05-07Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
(Please Type or Print All Information)
1. Construction ActivityOperator: (General permit coverage will be issued to -this operator. The Certification In Item #12 must be
signed by the appropriate person associated with this operator.)
Name: March Mountain Properties, LLC
Contact: David Brockman, Development Manager
Mailing Address: 1005 Heathercroft: Circle, Suite 100
City: Crozet State:VA Z]p: 22932 Phone: (702) 985--9088
Email address (if available): Dave@oldtrailvillage.com
Indicate if DEO may transmit general permit correspondence electronically: Yes ® No ❑
2. Existing General Permit Registration Number (for renewals only): VAR10-12-10 0 9 2 6
Name and Location of the Construction Activity,
Name: Old Trail Village Subdivision
Address (if available):
City: Crozet State: VA Zip: 22932
County (if not located within a City): Albemarle
Latitude (decimal degrees): 3 8- 0 3 --3 0 Longitude (decimal degrees): 7 8- 4 2- 3 8
Name and Location of all Off -site Support Activities to be covered under the general permit:
Names• N/A
Address (if
County (if not located within a City):.
Latitude (decimal
4. Status of the Cc
State: Zip:
Longitude (decimal degrees):
Activity (check only one): Federal ❑ State ❑ Public ❑ Private
5. Nature of the Constriction Activity (e.g., commercial, Industrial, residential, agricultural, oil and gas, etc.):
Resideni ial
6. Name of the Receiving Water(s) and Hydrologic Unit Code (HUC):
Name: Lickinghole Creek Name:
HUC: JR02 HUG:
7. If the discharge Is through a Municipal Separate Storm Sewer System (MS4), the name of the MS4 operator:
8. Estimated Project Start and Completion Date:
Start Date (mm/dd/yyyy): 0 5 - 31- 2 014 Completion Date (mm/dd%W): 0 5- .31=2 Olt 9
9. Total Land Area of D6velopment (to the nearest one -hundredth acre): 91.71
Estimated Area to be Disturbed (to the nearest one -hundredth acre):_ • 71
10. Is the area to be disturbed part of a larger common plan of development or sale? Yes ® No ❑
11. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the General
VPDES Permit for Dli charges of Stormwater from Construction Activities prior to submitting this Registration Statement.
By signing this Regi$tration Statement the operator is certifying that the SWPPP has been prepared.
12. Certification: "I certify under penalty of law that I have read and understand this Registration Statement and that this document
and all attachments were prepared In accordance with a system designed to assure that qualified personnel properly gathered and
evaluated the information submitted. Based on my inquiry of the person or persons who manage the system or those persons
directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief true,
accurate, and complete. I am aware that there are significant penalties for submitting false information including the possibility of
tine and imprisonment for knowing violations,` tt
Printed Name: U1� Title: YtiYe�-cc�t11�
Signature: Dale: 5�
(Please sign in INK. Thqs Certi ' tion must be signed by the appropriate person associated with the operator identified in
Item'#1.)
01/2014 Page 1 of 1
DEPARTMENT OF ENVIRONMENTAL QUALITY
CONSTRUCTION ACTIVITY OPERATOR PERMIT FEE FORM
(Please Type or Print All Information)
Instructions: Applicants for a Construction Activity Individual Permit are required to pay permit application fees. Fees are
also required for registration for coverage under a Construction Activity General Permit. Fees must be paid when
applications for state permit issuance, reissuance, modification or transfer are submitted. Applications will be considered
incomplete if the proper fee is not paid and will not be processed until the fee is received.
The fee schedule for state permits is included with this form. Fees for state permit issuance, reissuance, maintenance,
modification and transfer are included. Once you have determined the fee for the type of application you are submitting,
complete this form. The original copy of the form and your check or money order payable to "Treasurer of Virginia"
should be mailed to:
Department of !Environmental Quality
Receipts Control
P.O. Box 1104
Richmond, VA'23218
A copy of this form and a copy of your check or money order should accompany the permit application (or registration
statement). You should retain a copy for your records.
Construction Activity Operator:
Name: MARCk W01ANT40,,j �20 pCf�..j I �� ,; LL C
Contact: DA Nt I _ epLI-em -rJ
Mailing Address: 100 5 440A'T C— R,(—LO FI L I IU LE, i E i 0 c0
City: L � ZE'T~ State: d A Zip: Z2532 Phone: 702 - 98 6 _ y o'8
Email address (if available): DhV C 6 0L1-3 6 6?-(Ai" l LL-A6E• Le ev\
Name and Location of the Construction Activity:
Name: OLT) W I LLA6 C Su om i V i S i 0 AJ
City: It s- State: VA Zip: Z 2 g L
County: -A 1—l�Fllrt �} a L_t
Type of State Permit: ❑ Construction Activity Individual Permit tA Construction Activity General Permit
(from Fee Schedule)
Type of Action: ❑ New Issuance N Reissuance ❑ Maintenance
❑ Modification ❑ Transfer
Amount of Fee Submitted (from Fee Schedule): 4 (�O 1 O®. Cy a
Existing General Permit Registration Number (if applicable): ��� I� " �Z n09Z4.
FOR DEQ USE ONLY
Date: DC #:
0112014 Page 1 of 1