HomeMy WebLinkAboutWPO202200001 Application 2022-01-17Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
Project Name:
Southern Albemarle Convenience Center
(The name should be the same as it appears on plans)
Is this an amendment, modification, or transfer of an approved plan? Yes ❑ No N
Is this a resubmission for review? Yes ❑ No N
@I
County File Number: WPO- (to be provided by the County for new applications)
The following are required elements of new applications [§]7-401]. For amendments and resubmission,
please indicate which items are being amended. Signatures must be provided for any submission.
B A. 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 a upon the property as required to ensure
compliance with the approved plans and permits. n
12100-00-00-082A2 County of Albemarle C/O Finance \
Tax Map & Parcel Print Name of Owner
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:
PrintName: County of Albemarle C/O Finance - Lance Stewart (Director)
Address:
401 McIntire Road
City:_ Charlottesville
Daytime Phone: (434)296-5816 x3409 _E-mail: Istewart@albemarle.org
VA yin, 22902
Revised 07/1/21; 7/26/2021
❑ 13. All Fees [Code §17-208]
For new or modified plans: Total acres proposed to be disturbed
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)
❑ C. Registration Statement on the official DEQ form.
❑ D. Erosion and Sediment Control Plan satisfying the requirements of Code § 17-402.
❑ E. Stormwater Management Plan satisfying the requirements of Code § 17-403.
❑ F. Pollution Prevention Plan satisfying the requirements of Code § 17-404.
❑ 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
Address:
City:
Daytime Phone: () 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 1§ 17-2081.
FOR OFFICE USE ONLY WPO #
Fee Amount $ Date Paid By who? Receipt # Ck# By:
Revised 07/1/21, 7/26/2021