HomeMy WebLinkAboutWPO201800085 Application WPO VSMP 2019-01-08Virginia Stormwater Management Program (VSMP) & .r
Application for Albemarle County
Project Name: TMP-18-34F1-G Residence.
(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 Fite Number: (to be provided by the Count},for new applications)
The following are required elements of new applications f om 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 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. i /
18-34F1-G Lick Mountain LLC
Tax Map & Parcel Print Name of Owner
i ax map & rarcei Print Name of Owner
i ax map & Parcel Print Name of Owner
Signature of
Signature of Owner
Signature of Owner
1 � a67 /
Date
Date
Date
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Contact Information for the Owner(s) to receive correspondence:
Print Name
Mark Lyons
Address
PO Box 331
City
Free Union
VA Zip 22940
Daytime Phone 4( 34) 249-0565 E-mail mlyonsivy@gmail.com
Revised 07/24/18 Page 1 of 2
R B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed
3.18
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
0 C. Registration Statement on the official DEQ form.
0 D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
a E. Stormwater Management Plan satisfying the requirements of code section 17-403.
0 F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
e 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 17-422.
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 Justin Sh
Address 912 East High St.
City Charlottesville state Virginia -Zip 22902
Daytime Phone (434) 227-5140 E-mail justin@shimp-engineering.com
*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:
Revised 07/24/18 Page 2 of 2