HomeMy WebLinkAboutWPO202000043 Application 2021-08-11Virginia 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 Counryfor new applications)
The following are required elements of new applications [from code section 17-401 J. 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
X j;'44�7- 8/10/2021
Tax Map & Parcel Print Name of Owner Signature of Owner Date
ly,41;e�-- 8/10/2021
Tax Map & Parcel Print Name of Owner Signature of Owner Date
/��✓� 8/10/2021
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
Daytime Phone
Revised 07/1/21 (Fee Update)
❑ B. All Fees [Code section 17-208]
For new or modified plans: Total acres proposed to be disturbed
Acres to
Total
Fee Due
Transfer or
be
Fee
with this
Modification
Disturbed
Application
Fee
Single Family Dwelling only
$237
$165
$23
Less than 1 acre
Single Family Dwelling only
$237
$165
$227
1 and less than 5 acres
Less than 1 acre
$237
$165
$20
1 and less than 5 acres
$2,204
$1,530
$227
5 and less than 10 acres
$2,775
$1,927
$283
10 and less than 50 acres
$3,673
$2,550
$340
50 and less than 100 acres
$4,979
$3,458
$510
100 acres or more
$7,835
$5,440
$793
Technology Surcharge: 4% applied to each fee.
❑ 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 ofall plans and any supporting documents or submit all documents online. 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, consultan( or agent):
RFSm
Address
City
Daytime Phone O 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. Active permits are subject to annual maintenance fees 117-2081.
FOR OFFICE USE ONLY
WPO #
Fee Amount $ Date Paid
By who?
Receipt
Revised 07/1/21 (Fee Update)