HomeMy WebLinkAboutWPO202200043 Application 2022-10-21Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
t� V U Project Name:
(The name should be the same as it ap1mars on plans)
Is this an amendment to an approved plan? Yes ❑ NoJ
Is this a revision or resubmission for review? Yes ❑ Nod/
County File Number:
G
(to be provided by the County for new applications)
The following are required elements ofnew 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 Property 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 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 Ma & Parcel Print Name of Prbperty Odmer Signature of Owner Date
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Tax Ma & Parcel Print Name of 'Property Owner Signature of Owner ate
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Tax Map & Parcel Print Name o Property Owner Signature of Owner Date
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Tax Map & Parcel Print Name of Pro Arty Owner Sienature o Owner Date
Contact Information for the Owner(s) to receive correspondence:
Print
Address
City
Daytime Phone (o} d 0^U3Jv7 E-mail
State VA Zip 0-g90
711/14, Revised 7/10/14, 1/7114 Page 1 of
A. Signature of the Property Owner for each parcel (Continued):
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Tax Map & Parcel Print Name of Property Owner
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Tax Map & Parcel Print
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of Property Owner
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Tax Map & Parcel Print Name of Property of Owner
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Signature of Owner
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Date
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re of Owner Date
Signature of Owner
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Date
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❑ B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed i
Acres to be
disturbed
Total Fee
Fee Due with this
cation
Fee with Transfer or
modification of permit
Less than 1
$290
$145
$20
1 and less than 5
$2,700
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 (per request)
Mitigation Plan; $150
❑ C. Registration Statement on the official DEQ form.
❑ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
❑ E. Stormwater Management Plan satisfying the requirements of code section 17-403.
❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405.
❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of
stream buffers.
❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408.
❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the
requirements of code section 17-422.
Provide 2 copies of all plans and any supporting documents. Professional seals must have original
signatures.
Additional information if not provided on plans and documents. -
Name of a Contact Person for correspondence (usually the plan preparer, consultant or agent)
Print
Address
City
Daytime Phone () E-mail
State Zip
*When applications and plans are reviewed, but not approved, and a response to comments is not received within 6 months
from the date of county comments, the application will be deemed withdrawn. Applications without valid owner's
signatures will not be considered valid.
FOR OFFICE USE ONLY
WPO #
Fee Amount$ Date Paid
By who?
Receipt
Cldl By:
7/1/14,Revised: 7/10/14,U7/14 Page 2of2