HomeMy WebLinkAboutWPO202100059 Application 2021-10-25Virginia Stormwater Management Program (VSMP)
Application for Albemarle ('ounh
Project Name- Crozet Self Storage 17'k-J/a•'\iu..IIi4' Ilk 'jaA-a, aWl(v- IIPIIa.i Na VI VI
Is this an amendment, modification, or transfer of an approved pion? ties i I
Is this a resubmission for review? Yes ❑ No W
County File Number: WPO_
(hi Iw provided by tiff Comao for new
a Itcatinns)
The jollowirtg are required elements ojnew applications 1,417-401/. Far amcndmenis r»ul rt'•suhmissions•
please indicate which iiems are Acing amended. Signatures muvi be provided for any submission'
X A. Signature of the Owngr for each parcel: (Required with every submission, NOT TO BF. SI(;NFD BY
AN AGENT OR CONSULTANT)
As signing this application as the owner, I hereto certify that all requirements of these plans and permits will be
complied with, and 1 hose the authority to aulhorhe 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 enure
compliance with the approved plans and permits.
05600-00-00-03200
Yousef LC Date
Tax Map &Parcel Print Name of (�na e
05600-00-00-032AO /%/ �� Z
Yousef LC
Tax .Map & Pwcel Print Name of (brner t c f o Dale
Tax Map & Parcel Print Name of owner Signature of Owner
Tax Map & Parcel Print Name of Owner Signature of (honer
Contact Information for the Owner(s) to receive corespondence:
Print Narne: Yousef LC
MBV�ImygT 1 I NO
Date
Date
city: Charlottesville state: VA 71p: 22903
y3 y-
a
Revised 0711/21; 7126N2021
013. All Fees [Code §17-208]
For new or modified plans: Total acres proposed to be disturbed 2.05 Ac.
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
1 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+$9.08)
5 and less than 10 acres
$2,004.08
$294.32
($1,927+$77.08)
($283 + $11.32)
10 and less than 50 acres
$2,652.00
$353.60
$2,550+$102
$340+$13.60
50 and less than 100 acres
$3,596.32
$530.40
($3,458 + $138.32)
($510 + $20.40)
100 acres or more
$5,657.60
$824.72
($5,440 + $217.60)
($793 + $31.72)
El C. Registration Statement on the official DEQ form.
IN D. Erosion and Sediment Control Plan satisfying the requirements of Code § 17-402.
® E. Stormwater Management Plan satisfying the requirements of Code § 17-403.
IN F. Pollution Prevention Plan satisfying the requirements of Code § 17-404.
IN 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)
❑ I. Requested Variations or Exceptions as provided in Code § 17-407 and § 17-408. $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): Clint Shifflett, PE
Address: 608 Preston Avenue Suite 200
cityCharlottesville
VA Tin 22903
Daytime Phone: 634) 327-1690 E-mail: clint.shifflett@timmons.om
• 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 1§ 17-2081.
FOR OFFICE USE ONLY WPO #
Fee Amount $ Date Paid By who? Receipt # Ck# By:
Revised 07/1/21, 7/26/2021