HomeMy WebLinkAboutWPO202300013 Application 2023-02-27Virginia Storfalwater Management Program (VSMP) t�
Application for Albemarle County
r, ", I� �" I �%Ru9N�P
Project Name: 9UgCXI C �arin , Ph. A i laL $ a�
(The name should be the same as it appears on plans) /
Is this an amendment to an approved plan? Yes ❑ No rd
Is this a revision or resubmission for review? Yes ❑ No l/
County File Number: (to be provided by the Countyfor new applications)
The following are required elements of new applications (from code section 17-401 j. 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 permjjs.
William D. Croaq r
M%-co,w-ddoic)D irt,;r, .mac, /Aw I7 //- -'6 3
Tax Map & Parcel Print Name of Prope Owne Signature of Owner
Wllbarn D,
�A1130 CO-f� G�e� L-nkr_rls�s,�i,c• MM
Tax Map &Parcel Print e of Properry Otvne Signature of Owner
Wuictry. m. tr
�IP�o•clJ.co.oaLloo 6a;g Efi-it* DF,sos. --L%.
Tax Map & Parcel Prm ne of Property Owner Signature of Owner
'William D. a-aw-for
03Vi 0-m.l1-off 6-�Lq GA -ises, -1
Tax Map & Parcel Print Nalne of Property Owner Signature of Owner
Contact Infonnation for the Owner(s) to receive correspondence:
Print Name V V I l l iam T. i,lra,la CIO Crai_a E)4 -D n i SaS , Toc .
Date
Address_Y 0 11P—*Oy b�J(�p ✓ 1 �
City chAY1OSVI at State UA Zip OqMt
v 0
Daytime Phone �'Q-03ko `T E-mail W l I amdora in o a mcal i corn
7/1/14, Revised: 7/10/14, 1/7/14 Page 1 of 2
A. Signature of the Property Owner For each parcel (Continued):
r, iIIiom D. -G-
G*rpn15e5,�rX-
Tax Map & Parcel Print Name of Property Owner Signature of Owner Date
1/Vilul�ieam D. i �r
i1&-DDT-CmDo .1 rInIses Tnc. I i� a�ao�3
Tax Map & Parcel
Tax Map & Parcel
Print Name of Property Owner
Print Name of Property Owner
Signature of Owner
Signature of Owner
Date
Date
❑ 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
A lication
Fee with Transfer or
modification of permit
Less than I
$290
$145
$20
l 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 (per request)
Mitigation Plan; $150
❑ C. Registration Statement on the official DEQ form.
❑ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
❑ E. Stormwater Management Plan satisfying the regiurements of code section 17-403.
❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404,
❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405.
❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of
stream buffers.
❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408.
❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the
requirements of code section 17-422.
Provide 2 copies of all plans and any supporting documents. Professional seals must have original
signatures.
Additional information if not provided on plans and documents:
Name of a Contact Pet -son
' for correspondence
-(usuually the plan preparer, consultant o agent)
Print Name l � pia k(%�(S�7(�ws
Address
City _ C�wDIRSVI State, _Up Zip 2�"'1O 1
Daytime Phone CA4) q73 -.5 - (9a E-mail na. I 1 t stQrJ—Q,tp 1 tlil&r,I1r5 . W M
*When applications and plans are reviewed, but not approved, and a response to comments is note received within 6 months
from the date of county comments, the application will be deemed withdrawn. Applications without valid owner's
signatures will not be considered valid.
FOR OFFICE USE ONLY
WPO #
Fee Amount$ Dale Paid
By who?
Receipt #
Ck# By:
7/1/14, Revised: 7/10/14, 1/7/14 Page 2 of