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Home My WebLink AboutWPO201600020 Application 2016-03-28 ;r1 Albemarle 'ounty401 McInCommunity Development Departn tire Road Charlottesville.VA 22902-4: Apoo Your Voice:(434;296-5832 Fax: (434)972-4 Planning Application 'PARCEL/ OWNER INFORMATION IMP 03260-00-00-000130 Owner(s): WOODBRIAR ASSOCIATES Application # WP0201600020 PROPERTY INFORMATION Legal Description 1 TRACT B Magisterial Dist. Rio Land Use Primary Forest Current AFD Not in A/F District Current Zoning Primary Cl Commercial APPLICATION INFORMATION Entered Street Address Judy Martin Application Type Water Protection Ordinances 13/28/2016 Project BrianArood Gas Station - VSMP Received Date 03/25/16 Received Date Final Submittal Date 03/25/16 Total Fees —1-3 Closing File Date Submittal Date Final Total Paid 13 Revision Number Comments Le-gal Ad SUB APPLICATION(s) Type Sub Application Comment APPLICANT/ CONTACT INFORMATION Contactlype Name Address CityState Zip Phone PhoneCf Owner/Applicant W OOD BRIAR ASSOCIATE P 0 BOX 5548 CHARLOTrESVILL 22905 Applicant H. DEXTER MUMAW P. 0. BOX 6 .MT. JACKSON, VA. 22642 5403332479 Primary Contact .H. DEXTER MUMAV.' P.O. BOX 6 NIT. JACKSON, VA. 22642 5403332479 Signature of Contractor or Authorized Agent Date Niue -- p AL Virginia Stormwater Management Program (VSMP) ,it�; ,p Application for Albemarle County t�RGtN�� Project Name: Briarwood Gas Station (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No 0 Is this a revision or resubmission for review? Yes ❑ No County File Number: WP0201400059 (to be provided by the County for new applications) The following are required elements of new applications[from code section 17-4011 For revisions or amendments,please indicate which items are being amended. Signatures must be provided for any submission. (14 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. • 032G0-00-00-000B0 Route 29 Briarwood, LLC 1 JA / 3/23/16 Tax Map&Parcel Print Name of Property Owner Signature of 0 •r Date Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name H. Dexter Mumaw P.O. Box 8 Address Mt. Jackson. Va. 22842 City State Zip Daytime Phone( 549 333-2479 E-mail chh@shentel.net 7/1/14, Revised: 7/10/14 Page 1 of 2 ❑ B. All Fees [Code section 17-208] For new or modified plans; Total acres proposed to be disturbed Acres to be Total Fee Fee Due with this Fee with Transfer or disturbed Application modification of permit Less than 1 $290 $145 $20 1 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 $6,100 $3,050 $450 100 100 and more $9,600 $4,800 $700 For(minor)amendments to an approved plan; $200 per review Variances;$150 Mitigation Plan;$150 ® C. Registration Statement on the official DEQ form. Ei D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. El E. Stormwater Management Plan satisfying the requirements of code section 17-403. ID F. Pollution Prevention Plan satisfying the requirements of code section 17-404. El G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents. Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name k. D C,d1S P MUMA it/ Address P'C7 '(3 ov- Q' City TAT - CJ=5Ow ' State VA Zip '2.3.$ Lt- Daytime Phone(slv) 333 2 9.7C( E-mail A- 1-J)S 1*1 ft6l.. h)F T- *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$j3Jt; ' Date Paid;3124(p By who?,,ii - 11-M(.111 a Cay P Receipt#1051-12 Ck# 0ZtP By: 7/1/14,Revised: 7/10/14 Page 2 oft Section 9. Signed Certification (Provide certification according to 9VAC25-870-370. For purposes of plan review and approvals. this certification should he the owner of the property, the same signature as appears on the bonds and applications. Another operator can he designated on the delegation of authority form to follow.) CERTIFICATION "I certify under penalty of law that I have read and understand this document 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." Owner/Operator Name: William B. Holtzman Company: Route 29 Briarwood, LLC Title: Manager Signature: ;11 Date: 3/23/16 Issued— 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County