HomeMy WebLinkAboutWPO201900002 Application 2019-01-09Virginia Erosion and Sediment Control Program (VESCP) x .
Application for Albemarle County 'ram
(This application is only to be used for projects exempt from the Virginia
Stormwater Management Program, VSMP, and the DEQ General Permit)
Project Name: OFFSITE STAGING/STOCKPILE PLAN FOR HOLLYMEAD DAM SPILLWAY IMPROVEMENTS
(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: WP0201800039 (EXISTING) (to be provided by the County for new applications)
The following are required elements of new applications [from code section ]7-401 J. 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.
46B 4-4
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Contact Information for the Owner(s) to receive correspondence:
Print Name MIKE CARMODY
Address 7610 VILLAGE HIGHWAY
City CONCORD State VA Zip 24538
Daytime Phone 4( 34) 993-2214 E-mail MCARMODY@BURLEIGHCONSTRUCTION.COM
7/1/14_ Revised- 7/10/14. 1/7/15. 10/17/19 Page I of
® B. All Fees [Code section 17-207]
Total acres proposed to be disturbed 0.0
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
fEE
® 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 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 JEREMY FOX
Address 172 SOUTH PANTOPS DR. STE. A
City CHARLOTTESVILLE
State VA Zip 22911
Daytime Phone (434) 979-8121 E-mail JFOX@ROUDABUSH.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:
7/1/14_ Revised- 7/10/14. 1/7/15. 10/17/19 Pape 2 of