HomeMy WebLinkAboutWPO201500063 Application 2021-05-06Virginia Stormwater Management Program (VSMP)�
Application for Albemarle County
�IACAN�P
Project Name: Virginia Asphalt Services
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes 0 No ❑
Is this a revision or resubmission for review? Yes la No ❑
County File Number: WP02015-63 (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.
0 A. Signature of the Property 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 Property Owner
of Owner
Tax Map & Parcel Print Name of Property Owner Signature of Owner
Tax Map & Parcel Print Name of Property Owner Signature of Owner
Tax Map & Parcel Print Name of Property Owner
Contact Information for the Owner(s) to receive correspondence:
Print Name Alan Franklin, PE
Address 427 Cranberry Lane
City Crozet
Date
Date
Date
Signature of Owner Date
State VA Zip 22932
Daytime Phone (434) 989-5703 E-mail bryan_heilman@yahoo.co
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® B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed n/a
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 (per request)
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.
0 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 ofall 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 Alan Franklin, PE
Address 427 Cranberry Lane
City Crozet
State VA Zip 22932
Daytime Phone (434) 531-5544 E-mail alan@alanfranklnpe.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:
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