HomeMy WebLinkAboutWPO202100035 Application 2021-09-17Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
�IACAN�P
Project Name: Airport Rd. Pump Station
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes ❑ No 91
Is this a revision or resubmission for review? Yes ® No ❑
County File Number: WP02021-00035 (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.
03200-00-00-041A2 Rivanna Water and Sewer
7) rr 9/17/2021
Tax Map & Parcel
Print Name of Owner
Kignature 6f 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 Rivanna Water and Sewer Authority - clo Michelle
Address 695 Moores Creek Lane
City Charlottesville
Daytime Phone (434) 997.2970 E-mail msimpson@rivanna.org
VA Tin 22902
Revised 07/24/18 Page 1 of 2
® B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed 119
Acres to be
disturbed
Total Fee
Fee Due with this
Application
Fee with Transfer or
modification of permit
Less than 1
$290
$145
S20
1 and less than 5
$2,700
$1,350
S200
5 and less than 10
$3,400
$1,700
S250
10 and less than 50
S4,500
$2,250
S300
50 and less than
100
$6,100
$3,050
S450
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 Brad Weiss
Address 3535 Vadnais Center Drive
City St Paul -State-MN Zip 55110
Daytime Phone (651 1 318-0349 E-mail bweiss@sehine.eom
*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 Amowt $ Date Paid
By who?
Receipt #
Ck# By:
Revised 07/24/18 Page 2 of