HomeMy WebLinkAboutWPO201100071 Application 2023-03-08Virginia Storm,
Application for
Project Name:
Management Program (VSMP)
narle County
STATION
MR name should be the same as it appears on plans)
Is this an amendment, modification, or transfer of an approved plan? Yes m No ❑
Is this a resubmission for review? Yes ❑ No
County File Number: O- WP0201100071 (to be provided by the Countyfor new applications)
The following are required elements of new applications [§]7-401]. For amendments and resubmissions,
please indicate which ite s are being amended. Signatures must be provided for any submission.
m A. Signature of the Owner for each parcel: (Required with every submission, NOT TO BE SIGNED BY
AN AGENT ORCONSULTANT)
By signing this appl cation 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.
558-1
Tax M
N,-wo-+ q" i- u ,3,411 A
or owner
2/21 /23
Date
Tax Map & Parcel I Print Name of Owner Signature of Owner Date
Map & Parcel I Print Name
Contact Information r the Owner(s) to receive correspondence:
Print Name: i�IN (� h e I k C_ '�' n Inc) Lk(- -0-
Address: o O'L q �o \ /
city: �7 11 _ State _Zip: 3
Daytime Phone: �'/�_� �� E-mail: N� S �% V0 iV���
'T—
V706 -�5 PI
Revised 07/I/21; 7/26/2021; 4/26/2022
❑ B. All Fees [Code 17-208]
For new or d'f
10 C. An
❑ D. Rel
❑ E. Etc
m F. Sto
❑ G. Pol
❑ H. Sto
❑ I. Mil
stre
❑ J. Rec
techi
Provide 2 c
seals must
Additional
Name of a Cc
Nam
Add
mo 1 led I
: Total acres ro osed
to be disturbed
Fee Due with this Transfer or
Acres to be
isturbed
Application Modification Fee
Total Fee = (Application Fee + 4% Technology Surcharge)
Single Famil
Dwelling only
$171.60
$23.92
Less than 1
re
($165+$6.60)
($23+$0.92)
Single Famil3
Dwelling only
$171.60
$236.08
1 and less that
15 acres
($165+$6.60)
($227+$9.08)
Less than 1 aere
$171.60
$20.80
($165+$6.60)
($20+$0.80)
1 and less tha
15 acres
$1,591.20
$236.08
($1,530 + $61.20)
($227+$9.08)
5 and less than
10 acres
$2,004.08
$294.32
($1,927 + $77.08)
($283 + $11.32)
10 and less th
in 50 acres
$2,652.00
$353.60
$2,550+$102
$340+$13.60
50 and less th
in 100 acres
$3,596.32
$530.40
($3,458+$138.32)
($510 + $20.40)
100 acres or more
$5,657.60
$824.72
($5,440 + $217.60)
($793 + $31.72)
lendments to an
approved plan. Fee = $236.08 per review ($227 fee + $9.08 technology surd
;istration Statement
on the official DEQ form.
sion and Sediment
Control Plan satisfying the requirements of Code §17-402.
rmwater Mani
gement Plan satisfying the requirements of Code § 17-403.
lution Prevent
on Plan satisfying the requirements of Code § 17-404.
rmwater Pollu
ion Prevention Plan satisfying the requirements of Code § 17-405.
igation Plan si
Ltisfying the requirements of Code § 17-406 for any proposed disturbance c
am buffers. $176.80
($170 fee + $6.80 technology surcharge)
uested Variati
Dris or Exceptions as provided in Code §17-407 and §17-408. $176.80 ($17C
tology surcharge)
o ies o all 1
7ns and any supporting documents or submit all documents online. Profes
have original signatures.
information if
not provided on plans and documents:
mtact Person for
orrespondence (usually the plan preparer, consultant, or agent):
e (Print):
•ess:
Large)
if
fee + $6.80
eional
Daytime Phone: (� E-mail:
• 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_ Annlientinne with—i ..eta
signatures win not oe considered valid. Active permits are subject to annual maintenance fees 1§ 17-208].
FOR OFFICE USE ONLY wpO g
Fee Amount $ Dw Pai4�y who? Receipt