HomeMy WebLinkAboutWPO202000048 Application 2020-10-19Revised 07/24/18 Page 1 of 2
Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
Project Name:
(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: _ (to be provided by the County for 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 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.
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
Address
City State Zip
Daytime Phone ( ) E-mail
Revised 07/24/18 Page 2 of 2
□ B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed
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
□ C. Registration Statement on the official DEQ form.
□ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
□ E. Stormwater Management Plan 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)
Print Name
Address
City State Zip
Daytime Phone ( ) _ E-mail
*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.
Fee Amount $ Date Paid By who? Receipt # Ck# By:
WPO # FOR OFFICE USE ONLY
Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
Project Name: Mill Creek Industrial Lot 11
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes ❑ No 10
Is this a revision or resubmission for review? Yes ❑ No lia
County File Number: (to be provided by the Countyfor 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.
76M1-11 Mill Creek Industrial Develo
9/30/20
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 Mill Creek Industrial Development LLC
Address 11155 Fifth Street SW, Suite C
City Charlottesville
Daytime phone ($03) 704-1315
VA Tin 22902
nathan@grayfoxstrategic.com
Revised 07/24/18 Page 1 of
10 B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed 0.97 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
10 C. Registration Statement on the official DEQ form.
10 D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
10 E. Stormwater Management Plan 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)
Print Name SCOTT COLLINS - COLLINS ENGINEERING
Address 200 GARRETT STREET, SUITE K
City CHARLOTTESVILLE
VA 7in 22902
Daytime Phone (434) 293-3719 E-mail scott@collins-engineering.com
*When applications and plans are reviewed, but not approved, and a response to comments is not received within 6 mouths
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 Amowt $ Date Paid
By who?
Receipt #
Ck# By:
Revised 07/24/18 Page 2 of