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HomeMy WebLinkAboutWPO201700055 Application 2017-07-1900 woe Ac��r 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 7/1/14, Revised: 7/10/14, 1/7/15 Page 1 of `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: 7/1/14, Revised: 7/10/14, 1/7/15 Page 2 of