HomeMy WebLinkAboutWPO201600084 Other WPO VSMP 2016-12-15c` OV 11
Albemarle County Water Protection Ordinance
Request regarding development in a stream buffer
Required Information for application;
2 A. Signature of the Prope Owner for each parcel: (Required, NOT TO BE SIGNED BY AN AGENT,
BUILDER, CONSULTANT, or anyone other than the owner)
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. I
Z4-45�
Tax Map & Parcel
Contact Information for the Owner to receive
Print Name
Address 411
City
of Owner
Daytime Phone l Yt-1 I 0 — Zi3T, E-mail _I
State `� Zip ZZ GQZ
I G IOCAA. G01M
419 A description or drawing of the proposed disturbance. (Typically this is a driveway, house, garage,
grading activity, etc. It does not matter that it may be theoretical or exploratory. Any additional
information, like a professional stream or buffer assessment, will be helpful.)
FOR OFFICE USE ONLY WPO #
Fee Amount $ Date Paid By who? Receipt # Ck# By:
7/1/2014