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HomeMy WebLinkAboutWPO201400030 Permit 2014-04-15 sore Nftwel DEPARTMENT OF ENVIRONMENTAL QUALITY CONSTRUCTION ACTIVITY OPERATOR PERMIT FEE FORM (Please Type or Print All Information) Instructions:Applicants for a Construction Activity Individual Permit are required to pay permit application fees.Fees are also required for registration for coverage under a Construction Activity General Permit. Fees must be paid when applications for state permit issuance, reissuance, modification or transfer are submitted.Applications will be considered incomplete if the proper fee is not paid and will not be processed until the fee is received. The fee schedule for state permits is included with this form. Fees for state permit issuance, reissuance, maintenance, modification and transfer are included. Once you have determined the fee for the type of application you are submitting, complete this form. The original copy of the form and your check or money order payable to "Treasurer of Virginia" should be mailed to: Department of Environmental Quality Receipts Control P.O.Box 1104 Richmond,VA 23218 A copy of this form and a copy of your check or money order should accompany the permit application (or registration statement).You should retain a copy for your records. Construction Activity Operator: Name: WOODBRIAR ASSOCIATES Contact: WENDALL WOOD Mailing Address: P.O.BOX 5548 City: CHARLOTTESVILLE State: VA Zip: 22905 Phone: Email address(if available): Name and Location of the Construction Activity: Name: BRIARWOOD-BRIARWOOD DRIVE City: CHARLOTTESVILLE State: VA Zip: 22911 County: ALBEMARLE COUNTY Type of State Permit: ❑Construction Activity Individual Permit ©Construction Activity General Permit (from Fee Schedule) Type of Action: ❑New Issuance © Reissuance ❑Maintenance ❑Modification ❑Transfer Amount of Fee Submitted(from Fee Schedule): $750 Existing General Permit Registration Number(if applicable): VAR10-12-101227 FOR DEQ USE ONLY Date: DC#: • 01/2014 Page 1 of 1 • Registration Statement General VPDES Permit for Discharges of Stormwater from Construction Activities(VAR10) (Please Type or Print All Information) 1. Construction Activity Operator:(General permit coverage will be issued to this operator. The Certification in Item#12 must be signed by the appropriate person associated with this operator.) Name: WOODBRIAR ASSOCIATES Contact: WENDALL WOOD Mailing Address: P.O.BOX 5548 City: CHARLOTTESVILLE State: VA Zip: 22905 Phone: Email address(if available): Indicate if DEQ may transmit general permit correspondence electronically: Yes❑ No 2. Existing General Permit Registration Number(for renewals only): VAele- IZ 101221 3. Name and Location of the Construction Activity: Name: BRIARWOOD Address(if available): BRIARWOOD DRIVE City: CHARLOTTESVILLE State: VA Zip: 22911 County(if not located within a City): ALBEMARLE COUNTY Latitude(decimal degrees): 38.15944 Longitude(decimal degrees): -78.41833 Name and Location of all Off-site Support Activities to be covered under the general permit: Name: Address(if available): City: State: Zip: County(if not located within a City): Latitude(decimal degrees): Longitude(decimal degrees): 4. Status of the Construction Activity(check only one): Federal❑ State❑ Public© Private❑ 5. Nature of the Construction Activity(e.g.,commercial,industrial,residential,agricultural,oil and gas,etc.): RESIDENTIAL&COMMERCIAL 6. Name of the Receiving Water(s)and Hydrologic Unit Code(HUC): Name: NORTH FORK RIVANNA RIVER-JACOB'S RUN Name: HUC: JR11(020802040303) HUC: 7. If the discharge is through a Municipal Separate Storm Sewer System(MS4),the name of the MS4 operator: 8. Estimated Project Start and Completion Date: Start Date(mmiddlyyyy): el I0l J -Olo Completion Date(mm/dd/yyyy): 2.t 4, 9. Total Land Area of Development(to the nearest one-hundredth acre): 47 AC- Estimated Area to be Disturbed(to the nearest one-hundredth acre): 47 AC 10. Is the area to be disturbed part of a larger common plan of development or sale? Yes❑ No❑ 11. A stormwater pollution prevention plan(SWPPP)must be prepared in accordance with the requirements of the General VPDES Permit for Discharges of Stormwater from Construction Activities prior to submitting this Registration Statement. By signing this Registration Statement the operator is certifying that the SWPPP has been prepared. 12. Certification:"I certify under penalty of law that I have read and understand this Registration Statement and that this document and all attachments were prepared in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief true, accurate,and complete.I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment for knowing violations." Printed Name: U/4'ry 6'`r// it /L'tri l i b'� 4 i� ycc,�$U Title: i' 1,eL.,c�i ►t C-V tire. Signature: Date: $-;}—/51 (Please sign in INK. This Certification must be signed by the appropriate person associated with the operator identified in Item#1.) 01/2014 Page 1 of 1