HomeMy WebLinkAboutWPO202100036 Application 2021-06-30 (2)Virginia Stormwater Management Program (VSW)
Application for Albemarle County _
Project Name: g $,7reP (.Qn'o11 �d
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes ❑ No Ge
Is this a revision or resubmission for review? Yes ❑ No ®'
County File Number: (to be provided by the Countyfor new applications)
The fallowing 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.
7-4/6 W(Il i1,AN Ph 1Jr.j)ty W-' Ir /ti (its G/-1J2o2
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 PA. Wr;sl,+ /j1 L6er. ouwen5
Address r {� FT W Ln
City 5; 2-L &4+tsyiO4 State VA Zip Z2.9c5l
Daytime Phone 31 2 K 9- l 9 e 3 E-mail PAr)Cc r, W r ll i' Qq r n w) , l v -I
J
Revised 0724/1 S Page I of 2
S(B. All Fees [Code section 17-208)
For new or modified plans; Total acres proposed to be disturbed
2.32
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
VC. Registration Statement on the official DEQ form.
PAD. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
WrE. Stormwater Management Plan satisfying the requirements of code section 17-403.
❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
1(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 conies 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 Ct r'S Ar_,l�l )
Address f +Z G lii S't
City Cl lofksV,)� StateyA Zip Z2902-
Daytime Phone t(A 22E-mail C. 15 CON
`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 S Date Paid
By who?
Receipt W
Cld! By:
Revised 07/24/18 Page 2 of 2