HomeMy WebLinkAboutWPO202100048 Plan - Other (not approved) 2021-09-22 (2)O B. All Fees [Code § 17-208]
For new or modified plans: Total acres proposed to be disturbed 2l�
Fee Due with this
Transfer or
Acres to be Disturbed
Application
Modification Fee
Total Fee = (Application Fee+ 4% Technology Surcharge)
Single Family Dwelling only
$171.60
$23.92
Less than 1 acre
($165 + $6.60)
($23 + $0.92
Single Family Dwelling only
$171.60
$236.08
I and less than 5 acres
($165 +$6.60)
($227+$9,08)
Less than 1 acre
$171.60
$20.80
($165+$6.60)
($20+$0.80)
1 and less than 5 acres
$1,591.20
$236.08
($1,530 + $61.20)
($227+M08)
5 and less than 10 acres
$2,004.08
$29432
($1,927+$77.08)
($283 + $11.32)
10 and less than 50 acres
$2,652.00
$353,60
$2550+$102
5340+$13.60
50 and less than 100 acres
$3,596.32
$530A0
($3,458+$13832)
($510+$20.40)
100 acres or more
$5,657.60
$824.72
($5,440 + $217.60)
($793 + $31.72)
4b C. Registration Statement on the official DEQ form.
d D. Erosion and Sediment Control Plan satisfying the requirements of Code § 17-402.
1� E. Stormwater Management Plan satisfying the requirements of Code § 17403.
0 F: Pollution Prevention Plan satisfying the requirements of Code § 17-404.
Ct] G. Stormwater Pollution Prevention Plan satisfying the requirements of Code § 17-405.
❑ H. Mitigation Plan satisfying the requirements of Code § 17-406 for any proposed disturbance of
stream buffers. $176.80 ($170 fee + $6.80 technology surcharge)
❑ 1. Requested Variations or Exceptions as provided in Code § 17-407 and § 17408. $176.80 ($170 fee +$6.80
technology surcharge)
Provide 2 copies of all 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, consultant, or agent):
Name (Print): k ,A, r-
Address: 1`1Z, S wiL Pw kQpr "e— —
City: Cl.nrlot�vtL;A state: 1/4 Zip: ZZ9II i
Daytime Phone:(Yj 2)Zq-Drf9tl Pmail:Kl�,.relit-Lresotd,��..e,,•,�_dewje ,.,.v'C�cc�
* 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months from the date of county comments, the application will be deemed withdrawn.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 1017-2081.
FOR OFFICE ��UF�S(E//'O��N'L�Yjj�� wpo#
Fee Amount $ 00UI GItIpaid By who �,.� reip p HC. ,�Y;yJS
Rzvised 0711/21: 7/26/2021
Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
a
n
Project Name:e, veal ere �c�i �:�� SttM SA
(The name should be the saute as it appews on plans)
Is this an amendment, modification, or transfer of an approved plan? Yes ❑ No ❑
Is this a resubmission for review? Yes ❑ No &
County File Number: WPO- (to be provided by the County far new applications)
The following are required elements of new applications [¢17-401]. For amendments and resubmission,
please indicate which items are being amended. Signatures must be provided far any submission.
1�2eaA. Signature of the Owner for each parcel: (Required with every submission, 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 Owner Signature of Owner Date
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Tax Map & Parcel Print Namc of Owner Signature of Owner Date
Contact Information for the Owners) to receive correspondence:
Print Name: Fr &. Iil�
Address: 1_442- Aitu ,% t Ce-,ve_
City: r lv„r( SutKa State: VA Zip: 22t¢ It
Daytime Phone: ()Z4r+t)Rrvt/ E-mail:�is�'.Sc ti} rn—a� rr�ame,n� Cry
Revised 07/121; 726/2021