HomeMy WebLinkAboutWPO202100068 Application 2022-02-14 (2)pti ALg
Virginia Erosion and Sediment Control Program (VESCP) F `' '
Application for Albemarle County ''� _'"I
(This application is only to be used for projects exempt from the Virginia
Stormwater Management Program (VSMP))
Project Name: Nystrom Driveway Crossing
(The name should he 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 N
County File Number: WPO - Not yet assigned (to be provided by the Countyfor new applications)
The following are required elements of new applications (Code §17-401]. 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 aleti nd development on the subject
property. I hereby grant the County of Albemarle the right to enter uefi the erty as required to ensure
compliance with the approved plans and permits.
7-29A
Tax Map & Parcel Print Name of Owner
Tax Map & Parcel
Tax Map &
Print Name of Owner
Print Name of Owner
reT e-
Signature of Owner
Signature of Owner
Tax Map & Parcel Print Name of Owner Signature of Owner
Contact information for the Owner(s) to receive correspondence:
Print Name: Jonathan Nystrom
Address: 2417 Grove Ave
city: Richmond
1 /114
Date
Late
Date
Date
State: VA Zip: 23220
Daytime Phone: 9( 19)830-7191 E-mail: JgNystrom@nyeomine.com
7/1/14, Revised: 7/10/14, 1/7/15,10/17/18, 7/l/2021, 7/26/2021 Page l of2
® B. All Fees [Code § 17-207]
Total acres proposed to be disturbed 0.94
Acres to be Disturbed
Total Fee = (Application Fee + Technology Surcharge)
Less than 1 acre
$176.80 per review
($170 + $6.80)
1 acre or more
$353.60 per review
($340 + $13.60)
• C. Erosion and Sediment Control Plan satisfying the requirements of Code § 17-402.
Mitigation Plan submitted 10/l/21
• D. Mitigation Plan satisfying the requirements of Code § 17-406 for any proposed disturbance of stream
buffers. Fee = $176.80 per review ($170 fee + $6.80 technology surcharge)
WA. Requested Variations or Exceptions as provided in Code § 17-407 and § 17-408. Fee = $176.80 per
review ($170 fee + $6.80 technology surcharge)
Wk. Amendments to an approved plan. Fee = $236.08 per review ($227 fee _ $9.08 technology surcharge)
Provide 2 copies of all plans and any supporting documents or submit 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):
Print Name: Dustin Greene, PE
Address: 999 Second Street SE
city: Charlottesville
State: VA Zip: 22902
Daytime Phone: 4( 34) 328-1069 E-mail: dgreene@roudabush.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. Active permits are subject to annual maintenance
fees (§ 17-2071.
FOR OFFICE USE ONLY
wFo #
Fee Amount S Date Paid
By who?
Receipt #
Ck# By:
7/1/14, Revised: 7/10/14, 1/7/15, 10/17/18, 7/l/2021, 7/26/2021 Page 2 of