HomeMy WebLinkAboutWPO201700055 Application 2017-07-1900
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Virginia Erosion and Sediment Control Program (VESCP)
Application for Albemarle County-�
(This application is only to be used for projects exempt from the Virginia
Stormwater Management Program, VSMP, and the DEQ General Permit)
Project Name: Orchard Acres Water Main Replacement Project
('The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes ❑ No
Is this a revision or resubmission for review? Yes ❑ No
County File Number: U) `j` 5S (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.
055CO-00-OH-01600 Mary B. Hornbarger
Tax Map & Parcel Print Name of Property Owner Signature of Owner Date
055CO-00-OH-01500 Jerry W. Thacker & Sara E. Rugo
Tax Map & Parcel Print Name of Property Owner Signature of Owner Date
055CO-00-OH-01400 Anthony W. & Rebecca V.Hughes ON
Tax Map & Parcel Print Name of Property Owner Signature of Owner Date
055CO-00-OH-01300 James M. & Amanda M. Davis A
Tax Map & Parcel Print Name of Property Owner Signature of Owner Date
055CO-00-OH-01200 Martin F. & June S. Andrews 4.'
Tax Map & Parcel Print Name of Property Owner Signature of Owner Date
Contact Information for the Owner(s) to receive correspondence:
Print Name F k",der S. Moi r C'> on C ALS A )
Address Ib% Si.�" Ra.
City State 4 A Zip ZZ'44 c
Daytime Phone (`Q4) Q11-46'11 cra-it(, E-mail o.Yrno��;aonna Scr.�;u�a�.iL.o,:�,� ova
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`401e
❑ B. All Fees [Code section 17-207]
In
Total acres proposed to be disturbed 0.32 Acres
Acres to be disturbed
Total Fee
Less than 1
$150 per review
More than 1
$300 per review
For amendments to an approved plan; $200 per review
Variances; $150 (per request)
Exceptions; $240
Mitigation Plan; $150
Construction Record Drawing; $300
❑ C. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
❑ D. 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.
❑ F. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the
requirements of code section 17-422.
Provide 2 copies ofall 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 Charles Luck, P.E.
Address 9030 Stony Point Parkway Suite 220
City
Richmond
Daytime Phone (804) 272-8700 E-mail cluck(�wrallp.com
State VA Zip 23235
*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 e, WPO #
Fee Amount $ Date Paid /j '`/;` J y who? (1 `) T Receipt # / `/�_yC _ By:
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