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Home My WebLink AboutWPO201800077 Application 2022-04-12Virginia Stormwater Management Program (VSMP) Application for Albemarle County Project Name: Old Trail Block 32 WPO Plan Amendment (The name should be 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 El County File Number: WP0201800077 (to be provided by the Countvfor new applications) The following are required elements of new applications (from code section 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, 1 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. rl 55E-01-32-(34-4 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: Print Name DAVE BROCKMAN Address 1005 HEATHERCROFT CIR. SUITE 100 CROZET VA 7iu 22932 Daytime Phone ( ) E-mail DAVE@OLDTRAILVILLAGE.COM EI B. All Fees [Code section 17-208] For new or modified plans; Total acres proposed to be disturbed Acres to be disturbed Total Fee Fee Due with this Application Fee with Transfer or modification of permit Less than 1 $290 $145 $20 1 and less than 5 $2,700 $1,350 $200 5 and less than 10 $3,400 $1,700 $250 10 and less than 50 $4,500 $2,250 $300 50 and less than 100 $6,100 $3,050 $450 100 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. ❑ 1. 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 JEREMY FOX Address 608 PRESTON AVE SUITE 200 CHARLOTTESVILLE VA Tin 22903 Daytime Phone (434) 327-5382 E-mail JEREMY.FOX@TIMMONS.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. FOR OFFICE USE ONLY WPO N Fee Amount $ Date Paid By who? Receipt q Ckt1 By: