HomeMy WebLinkAboutWPO202100047 Application 2021-08-13Virginia Erosion and Sediment Control Program (VESCP)OD
Application for Albemarle County
(This application is only to be used for projects exempt from the Virginia
Stormwater Management Program, VSMP, and the DEQ General Permit)
Project Name: Clover Lake Dam Repair
(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 m
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 tproperty asprequired to ensure
compliance with the approved plans and permits. f t„�,`/jj✓ /,(Z �� (
059C2-02-00-03800 Joseph W. & Patricia B. Richmond
Tax Map & Parcel Print Name of Owner Signature of Owner /
059C1-02-00-00200 Shirley H. German, Trustee �; 2 i
Tax Map & Parcel Print Name of Owner S e 9 Ow i , ' Date
059C2-02-00-00100 Peter
Tax Map & Parcel Print Name of Owner
F. Martin
MAY r. IVAK rlAl
Tax Map & Parcel Print Name of Owner
Contact Information for the Owner(s) to receive correspondence:
West Leigh Lake Committee of Three - Steven Hiss
Address 2390 Kingston Road
City Charlottesville
Date
5--//-u
Date
State VA Zip 22901
Daytime Phone 4( 34) 987-5755 E-mail hiss.steven@gmail.com
7/1/14, Revised: 7/10/14, 1/7/15, 10/17/18
Page 11 f2 f
❑ B. All Fees [Code section 17-207]
Total acres proposed to be disturbed 0.49 acres
Acres to be disturbed
Total Fee
Less than 1
$150 per review
$150
More than 1
$300 per review
For amendments to an approved plan; $200 per review
Variances; $150 (per request)
Exceptions; $240
Mitigation Plan; $150
Construction Record Drawing;$300
❑ C. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
❑ D. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of
stream buffers.
❑ E. Requested Variations or Exceptions as provided in code sections 17-407 and 408.
❑ F. 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)
David A. Krisnitski. P.E.
Address 1734 Seibel Drive, NE
City Roanoke State VA Zip 24012
Daytime Phone (5401 632-7435 E-mail dkdsnitski@fandr.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 liDate Paid
By who?
Receipt #
Ck# By:
7/1/14, Revised: 7/10/14, 1/7/15, 10/17/18 Page 2 of 2