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Home My WebLink AboutWPO201400062 Application 2014-07-15Screening Form Number COUNTY OF ALBEMARLE Department of Community Development 401 McIntire Road, Room 227 Charlottesville, Virginia 22902 -4596 Phone (434) 296 -5832 Fax (434) 972 -4126 LAND DISTURBANCE EROSION AND SEDIMENT CONTROL SCREENING FORM This form is intended to aid the Department in classifying a land disturbance. The form responses will be used to determine whether a disturbance is subject to the County's Water Protection Ordinance. Failure to respond or to fully complete the screening form within 72 hours may require the Department to stop all land disturbing activity. The Stop Work Order will remain effective until the classification of the disturbance and/or obtainment of all required permits associated with the disturbance. Owner / Agent Name (Print) Home Phone Office / Other Phone Address City State Zip Code 1. Are there any streams on the property? Yes No 2. If so, will land disturbing activity be within 100' of the stream? Yes �� No 3. Will the project require grading, excavating, clearing, filling, or other land disturbing activity of any kind? Yes No Directions to Property and Location of Activity: P-/. 19571/) 1 Area to be disturbed: acies or sq. ft. j Owner / Agent Signature Date (FOR OFFICE USE ONLY) Tax Map /Parcel: _ _ _ Checked By October 9, 2006 Date Requires an Erosion and Sediment Control Plan Requires an Agreement in Lieu of an Erosion and Sediment Control Plan Exempt Activity Virginia Erosion and Sediment Control Program (VESCP) Application for Albemarle County NA Required Elements of this application [from code section 17 -4021: Provide 2 copies o all plans and any supporting documents. Professional seals must have original signatures. ❑ A. Signature of the Property wner 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 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 Sig ture Owner ate Tax Map & Parcel Signature of Owner Date Tax Map & Parcel Signature of Owner Date Tax Map & Parcel Signature of Owner Date Contact Information for the Owner(s) to receive correspondence: Print Name 1J W Address City _�jJ' a State Zip Daytime Phone(____) %�U / %ty E -mail i��L�%� L% ✓'�i e/ G� ❑ B. All Fees [Code section 17 -207] Total acres proposed to be disturbed �'Ly 4 _G Acres to be disturbed Total Fee Less than 1 $150 per review More than 1 $300 per review ❑ C. Registration Statement on the official DEQ form (attached). 7/1/2014 Albemarle Munty Planning Application W Community Development Department 401 McIntire Road Charlottesville, VA 22902 -4596 Voice: (434) 296 -5832 Fax: (434) 972 -4126 TMPI 02900- 00- 00 -041A0 Owner(s): CAMPBELL, BRUCE D OR PAULA Application # WP0201400062 PROPERTY INFORMATION Legal Description 1ACREAGE Magisterial Dist. White Hall Land Use Primary Residential -- Single- family (incl. modular homes) Current AFD Not in A/F District Current Zoning Primary Rural Areas LICATION INFORMATION Street Address 4261 FREE UNION RD CHARLOTTESVILLE, 22901 Entered By Application Type Water Protection Ordinances Jud Martin 06/30/2014 Project Campbell Residents Received Date 06/27/14 Received Date Final L� Submittal Date 06/30/14 Total Fees 150 Closing File Date Submittal Date Final Total Paid 150 Revision Number Comments Legal Ad SUB APPLICATION(s) Type Sub Applicati Comment Erosion and Sediment Conirtrl.Plan APPLICANT CONTACT INFORMATION ContactT Name Address CityState Zip Phone PhoneCell Owner /Applicant ;CAMPBELL, BRUCE D OR PAULA P O BOX 220 FREE UNION VA ;22940 a...............:.... _............... _ _..........:.........:...... ............................... _... a...................:.......... ............................... _.... _.........a........ ............................... a _...................... Primary Contact DAVID WYANT 4686 GARTH ROAD CROZET, VA. € 22932 :4349603978 € _ ............................................... ............................... _............... ............................... ................ z ................ t..................... ............ Signature of Contractor or Authorized Agent Date Application for Review of Erosion & Sediment Control Plan & Stormwater ManagementBMP Plan & Stream Buffer Mitigation Plan A Erosion & Sediment Control Plan ❑ Stormwater Management/BMP Plan ❑ Stream Buffer Mitigation Plan ❑ E &S Plan Amendment ❑ SWM Plan Amendment (Previous Plan # ) (Previous Plan # ) • E &S Plan with Variance ❑ Request for Exception # of Variances ❑ SWM Plan Resubmittal • E &S Plan Resubmittal WPO Application # WPO Application # _ Submit 2 copies each of applicable plans /narrative /computations *When a WPO plan is 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. Project Name: r�� / � �i /� Tax map and parcel: 2-1- 1 � Zoning: i vT Amount of Land Disturbance: &-,q, ,-/ Acres , / Location of property (landmarks, intersections, or other): F— f �l /�V �� /N �c �'/�� ✓ Contact Person (Who should we call/write concerning this project ?): � Address ' l �v + 492 City Daytime Phone (_) ��d ^� /'7, Fax #(_ Owner of Record r 40— 012 69U 4 State �— Zip 7 Z 9- i' Z E -mail l� �L"S°�/ ��f�'yt,�r7` 6-4• '0_X/ r � f Address 1'x`241 14 '/ /O City ��- /� State 0/� Zip Daytime Phone (_) Fax # C__) Contractor ._ Address Daytime Phone (_� /j Fax # L__) Plan Preparer —✓tdr t Address s Daytime Phone (___) Fax # (___) E-mail City State Zip E -mail City C0097-• '009S Zip E -mail Owner /Applicant Must Read and Sign By signing this application as owner, I hereby certify that all requirements of the approved Erosion Control Plan, Stormwater ManagementBMP Plan, and /or Mitigation Plan 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 appr ved Ian. 1' Signature of Owner, Contract aser Date �ex / ry Print Name Daytime phone number of Signatory FOR OFFICE USE ONLY j WPO # / % Fee Amount $ %5 ^� O Date Paid Z i �y who? bw ell-Ai ll S� Leipt # q 2- � � Ck# 3 C96 f By— Revised November 14, 2011 Pagel of 3 C, EROSION CONTROL PLAN: (SUBMIT 2 COPIES) Land disturbing activity pertaining to single family dwelling unit: 1. Plan Review ........ ............................... ................................... ............................... $150 per review (TO BE PAID AT TIME OF APPLICATION AND EACH SUBMITTAL THEREAFTER UNTIL APPROVAL) 2 Permit and First Year Inspection Fees ................................................ ............................... $150 (TO BE PAID PRIOR TO SCHEDULING PRECONSTRUCTION CONFERENCE FOR EROSION CONTROL PERMIT) 3. Annual Permit Renewal and Inspection Fees ..................................... ............................... $150 (TO BE PAID ANNUALLY, STARTING WITH SECOND YEAR, UNTIL COMPLETION OF APPROVED PLAN REQUIREMENTS) 4. Each reinspection ................................................................................ ............................... $150 (REINSPECTION FEES ARE INVOICED TO THE LANDOWNER) Land disturbing activity pertaining to nonexempt agricultural land: 5. Plan Review ........................................................................................ ............................... $150 per review (TO BE PAID AT TIME OF APPLICATION AND EACH SUBMITTAL THEREAFTER UNTIL APPROVAL) 6. Permit and First Year Inspection Fees ............................................. ............................... $150 (TO BE PAID PRIOR TO SCHEDULING PRECONSTRUCTION CONFERENCE FOR EROSION CONTROL PERMIT) 7. Annual Permit Renewal and Inspection Fees ..................................... ............................... $150 (TO BE PAID ANNUALLY, STARTING WITH SECOND YEAR, UNTIL COMPLETION OF APPROVED PLAN REQUIREMENTS) 8. Each reinspection ................................................................................ ............................... $150 (REINSPECTION FEES ARE INVOICED TO THE LANDOWNER) All other land disturbing activity: 9. Plan Review, Disturbed Area Less Than One Acre ............................ ............................... $150 per review (TO BE PAID AT TIME OF APPLICATION AND EACH SUBMITTAL THEREAFTER UNTIL APPROVAL) 10. Permit and First Year Inspection Fees, Disturbed Area Less Than One Acre ................... $200 (TO BE PAID PRIOR TO SCHEDULING PRECONSTRUCTION CONFERENCE FOR EROSION CONTROL PERMIT) 1.1. Annual Permit Renewal and Inspection Fees, Disturbed Area Less Than One Acre ........ $200 (TO BE PAID ANNUALLY, STARTING WITH SECOND YEAR, UNTIL COMPLETION OF APPROVED PLAN REQUIREMENTS) 12. Plan Review, Disturbed Area One Acre or Larger ............................. ............................... $300 per review (TO BE PAID AT TIME OF APPLICATION AND EACH SUBMITTAL THEREAFTER UNTIL APPROVAL) 13. Permit and First Year Inspection Fees, Disturbed Area One Acre or Larger .................... $100 /per disturbed acre (TO BE PAID PRIOR TO SCHEDULING PRECONSTRUCTION CONFERENCE FOR EROSION CONTROL PERMIT) 14. Annual Permit Renewal and Inspection Fees, Disturbed Area One Acre or Larger.......... $100 /per disturbed acre (TO BE PAID ANNUALLY, STARTING WITH SECOND YEAR, UNTIL COMPLETION OF APPROVED PLAN REQUIREMENTS) 15. Each reinspection ................................................................................ ............................... $250 (REINSPECTION FEES ARE INVOICED TO THE LANDOWNER) 16. Amendment to Approved Plan ........................................................... ............................... $180 /per plan review (TO BE PAID AT TIME OF APPLICATION AND EACH SUBMITTAL THEREAFTER UNTIL APPROVAL) 17. Variances ............................................................................................ ............................... $150 /per request (TO BE PAID AT TIME OF APPLICATION) 18. SUBTOTAL EROSION CONTROL PLAN ................................ ............................... $ ��, % Revised November 14, 2011 Page 2 of 3 STORMWATER MANAGEMENTBMP PLAN & MITIGATION PLAN: (SUBMIT 2 COPIES) 19. Stormwater Management/ BMP Plan ................................................ ............................... $300 /per plan review (TO BE PAID AT TIME OF APPLICATION AND EACH SUBMITTAL THEREAFTER UNTIL APPROVAL) 20. Major Amendment of Plan ............................................................... ............................... $180 /per plan review (TO BE PAID AT TIME OF APPLICATION AND EACH SUBMITTAL THEREAFTER UNTIL APPROVAL) 21. Request for exception ........................................................................ ............................... $240 (TO BE PAID AT TIME OF APPLICATION) 22. Request for development in a stream buffer or for reduction or modification of stream buffer and mitigation plan (if not part of another document) — Single family dwelling unit oraccessory structure .......................................................................... ............................... $85 (TO BE PAID AT TIME OF APPLICATION) -23.- Each - inspection- or- reinspection :.... ..................... :.......::................................ :.................... $60 - ( INSPECTION /REINSPECTION FEES ARE INVOICED TO THE LANDOWNER) 24. Mitigation Plan .................................................................................. ............................... $150 (TO BE PAID AT TIME OF APPLICATION) 25. SUBTOTAL SWM/BMP PLAN ...................................................... ............................... $ TOTAL APPLICATION FEE: (Add lines 18 and 25) ............... ............................... $ `��, " THE OWNER SHALL BE RESPONSIBLE FOR ALL REINSPECTION AND /OR ANNUAL RENEWAL FEES WHICH MAY BE CHARGED TO THIS PROJECT. Revised November 14, 2011 Page 3 of 3