HomeMy WebLinkAboutWPO202000031 Application 2020-06-01Virginia Stormwater Management Program (VSMP) 9
Application for Albemarle County
Project Name: BYERS FILL SITE
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes E7 No
Is this a revision or resubmission for review? Yves ❑ No
County File Number: (to be provided by the Countyfor 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 Owner, for each parcel: (Required with every submission or revision, NOT TO BE
SIGNED BY AN AGENT OR CONSULTANT)
By signing this applicatio4 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 upop the property as required to ensure
compliance with the approved plans and permits,
40-33HO Samuel
Tax Map & Parcel.
47-1 C
Print Name of Owner
Samuel
Tax Map & Parcel Print Name of Owner
Tad Map & Parcel Print Name of Owner
Tax Map & Parcel Print Name of Owner
Contact Information for the Owner(s) to receive correspondence:
Print Name SAMUEL F JIB BYERS
Address 2856 LAUREL COVE ROAD
Signature of Owner
f
Signature of Owner
�/23/.. o
� 25 -/.' C ?./)
Date
Signature of Owner Date
Signature of Owner Date
City CHARLOTTESVILLE State VA _Zip 22901
Daytime Phone (_) Email
Revised 07/24/18 Page t of 2
0 B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed 0.99 AC
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.
0 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.
0 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 Shim
Address 912 E High St.
City Charlottesville State VA 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