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Home My WebLink AboutWPO201900058 Application 2019-10-07 ofAl.*. Virginia Stormwater Management Program (VSMP) ;r ictsTo Application for Albemarle County %lie& Project Name: South Rivanna Water Treatment Plant Expansion and Improvement Project (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes 0 No EEI Is this a revision or resubmission for review? Yes 0 No El County File Number: (to be provided by the County for new applications) The following are required elements of new applications[from code section 17-4011 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. 45-68B (04500-00-00-068B0) c r—r � dr_ •Z /q 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 Rivanna Water and Sewer Authority-do Scott Schiller Address 695 Moores Creek Lane City Charlottesville State VA Zip 22902 Daytime Phone(434) 977.2970 E-mail sschiller@rivanna.org Revised 07/24/18 Page 1 of 2 M B. All Fees [Code section 17-208] For new or modified plans;Total acres proposed to be disturbed 2.29 Acres to be Total Fee Fee Due with this Fee with Transfer or disturbed _ Application 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 $6,100 $3,050 $450 100 100 and more $9,600 $4,800 $700 For(minor)amendments to an approved plan;$200 per review Variances;$150 Mitigation Plan;$150 ® C. Registration Statement on the official DEQ form. El D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. M E. Stormwater Management Plan satisfying the requirements of code section 17-403. M F. Pollution Prevention Plan satisfying the requirements of code section 17-404. 41 G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. O I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. O J. Construction Record Drawings (as-builts)for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name Douglas March Address 3299 Watts Passage City Charlottesville State VA Zip 22911 Daytime Phone(434) 409-0464 E-mail dmarch@sehinc.com *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months from the date of county comments,the application will be deemed withdrawn.Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO# �n lI -'513 Fee Amount$ Date Paid_------__ By who? Receipt# Ckfl By_--_-- Revised 07/24/18 Page 2 of 2 Aft, Virginia Stormwater Management Program (VSMP) `' Application for Albemarle County Project Name: South Rivanna Water Treatment Plant Expansion and Improvement Project (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No El Is this a revision or resubmission for review? Yes El No 0 County File Number: WPO-2019-00058 (to be provided by the County for new applications) The following are required elements of new applications[from code section 17-4011. 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 Iand disturbing activities and development on the subj- 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. Rhona( cy„"'et'E 45 6813 (04500-00-00-068130)JGwGr IA j�ovi f l/` l y , _ Tax Map&Parcel Print Name of Owner / Signature of Owner D to 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 Rivanna Water and Sewer Authority-do Scott Schiller Address 695 Moores Creek Lane City Charlottesville I State VA Nlzip 22902 Daytime Phone(434) 997.2970__.. E-mail ssehIlier@rivanna.org Revised 07/24/18 Page 1 of 2 • ®B. All Fees [Code section 17-208] For new or modified plans;Total acres proposed to be disturbed 2.29 Acres to be Total Fee Fee Due with this Fee with Transfer or disturbed Application modification ofpermit Less than 1 $290 $145 $20 Y 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 $6,100 $3,050 $450 , 100 100 and more $9,600 $4,800 $700 For(minor)amendments to an approved plan;$200 per review Variances;$150 Mitigation Plan;$150 ® C. Registration Statement on the official DEQ form. 41 D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. ® E. Stormwater Management PIan satisfying the requirements of code section 17-403. ® F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ® G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings(as-builts)for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) PrintName Douglas March Address 3299 Watts Passage City Charlottesville state VA Zip 22911 Daytime Phone(434) 409-0464 E-mail dmarch@sehtnc.com *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 mon from the date of county comments,the application will be deemed withdrawn.Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO fi i Fee Amount$ Date Paid By who? Receipt Cka BY._.. .... Revised 07/24/18 Page 2 of 2