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COUNTY OF ALBEMARLE
Community Development
401 McIntire Road
Charlottesville,Vriginia 22902-4596
(434)296-5832
EROSION CONTROL PERMIT
Date of Application: 07/08/2015
Permit Effective Date: 01/14/2016 Number: WPO-2015-00044
LANDOWNER: NA Bundoran Farm,LLC Phone: 4342604304
123 East Main Street
Charlottesville,VA22902
CONTRACTOR: Arnold Excavation Phone: (434)531-1414
P.O.Box 188
Batesville,VA22924
REPONSIBLE LAND James C.Arnold Phone: (434)531-1414
DISTURBER: P.O.Box 188
Batesville,VA22924
Certification/License#: 35690 Type: Responsible Land Disturber
Plans Prepared By: Waterstreet Studio
Plans Dated: 07/23/2015 Last Revised: 08/04/2015
Plans Entitled: Lot H8D-Bundoran Farm-Hightop Drive Location:
Dist. 0.98
Acreage:
Tax Map: 08600-00-00-107A0 Hydrological JM46
Unit:
Issued By:Kenny Thacker Title:Erosion Control Officer
-- 17 Signature Date
NNW" 'MVO'
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:NA Bundoran Farm, LLC
Contact:Josh Woodson
Mailing Address: 123 East Main Street
City:Charlottesville State:VA Zip:22902 Phone:(434)260-4304
Email address(if available):j•woodson@naturalretreats.com
Indicate if DEQ may transmit general permit correspondence electronically: Yes❑■ No❑
2. Existing General Permit Registration Number(for renewals only):
3. Name and Location of the Construction Activity:
Name: Bundoran Farm
Address (if available):Hightop Drive
City:North Garden State:VA Zip:22959
County(if not located within a City):Albemarle
Latitude (decimal degrees):37.9673 N Longitude (decimal degrees):78.6918 W
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
6. Name of the Receiving Water(s)and Hydrologic Unit Code(HUC):
Name: North Fork Hardware River Name:
HUC:JM-46 HUC:
7. If the discharge is through a Municipal Separate Storm Sewer System (MS4),the name of the MS4 operator:
Albemarle County
8. Estimated Project Start and Completion Date:
Start Date(mm/dd/yyyy):03/01/2016 Completion Date(mm/dd/yyyy): 10/15/2016
9. Total Land Area of Development(to the nearest one-hundredth acre):29.79
Estimated Area to be Disturbed (to the nearest one-hundredth acre):0.98
10. Is the area to be disturbed part of a larger common plan of development or sale? Yes ■❑ No n
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 N .Josh Woodson Title:General Manager
Signatur � Date:-70415
(Please si 'n INK. This Certification must be signed by the appropriate person associated with the operator identified in
Item#1.)
01/2014 Page 1 of 1
Instructions for Completing the Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
GENERAL stormwater pollution prevention plan or comply with other permit
conditions).
A.Coverage Under this General Permit.
The entities that are considered operators will commonly consist of the
Any operator applying for coverage under this general permit who is owner or developer of a project(the party with control of project plans
required to submit a Registration Statement (see Section B below) and specifications)or the general contractor(the party with day to day
must submit a complete Registration Statement to the Department. operational control of the activities at the project site which are
The Registration Statement serves as a Notice of Intent for coverage necessary to ensure compliance with the general permit).
under the General VPDES Permit for Discharges of Stormwater from
Construction Activities(VAR10). Provide the legal name(do not use a colloquial name),contact,mailing
address, telephone number, and email address (if available) of the
B.Single-family Residences. construction activity operator;general permit coverage will be issued to
this operator. Indicate if the Department may transmit general permit
Operators with an existing stormwater discharge or proposing a new correspondence electronically.
stormwater discharge associated with the construction of a single-
family residence separately built, disturbing less than one acre and Item 2: Existing General Permit Registration Number.
part of a larger common plan of development or sale is not required to
submit a Registration Statement, provided that the stormwater For reapplications only, provide the existing general permit registration
management plan for the larger common plan of development provides number for the construction activity. This item does not need to be
permanent control measures (i.e., stormwater management facilities) completed for new construction activities applying for general permit
encompassing the single family residence. coverage.
Operators of these types of discharges are authorized to discharge Item 3: Name and Location of the Construction Activity
under this general permit immediately upon the general permit's Information.
effective date of July 1,2014.
Provide the official name, street address(if available),city or county(if
C.To Apply for Permit Coverage. not located within a City)of the construction activity. Also, provide the
latitude and longitude in decimal degrees of the approximate center of
1. New Construction Activities. Any operator proposing a new the construction activity(e.g., N 37.5000,W 77.5000).
stormwater discharge from construction activities shall submit a
complete Registration Statement to the Department prior to the Name and Location of Off-site Support Activity Information.
commencement of land disturbance, unless exempted by Section B
above. Any operator proposing a new stormwater discharge from This general permit also authorizes stormwater discharges from
construction activities in response to a public emergency where the support activities (e.g., concrete or asphalt batch plants, equipment
related work requires immediate authorization to avoid imminent staging yards, material storage areas, excavated material disposal
endangerment to human health or the environment is immediately areas, borrow areas) located on-site or off-site provided that (i) the
authorized to discharge under this general permit and must submit a support activity is directly related to a construction activity that is
complete Registration Statement to the Department no later than 30 required to have general permit coverage; (ii)the support activity is not
days after commencing land disturbance; documentation to a commercial operation, nor does it serve multiple unrelated
substantiate the occurrence of the public emergency must construction activities by different operators; (iii) the support activity
accompany the Registration Statement. does not operate beyond the completion of the construction activity it
supports; (iv) the support activity is identified in the registration
2. Existing Construction Activities. Any operator that was statement at the time of general permit coverage; (v) appropriate
authorized to discharge under the general permit issued in 2009, control measures are identified in a SWPPP and implemented to
and who intends to continue coverage under this general permit, address the discharges from the support activity areas; and (vi) all
shall submit a complete Registration Statement to the Department applicable state, federal, and local approvals are obtained for the
on or before June 1,2014,unless exempted by Section B above. support activity.
D.Where to Submit Registration Statements. Provide the official name,street address(if available), City and County
(if not located within a City) of all off-site support activities to be
All Registration Statements should be submitted to: covered under this general permit. Also, provide the latitude and
longitude in decimal degrees of the approximate center of the off-site
Department of Environmental Quality support activities (e.g., N 37.5000, W 77.5000). Also, if an off-site
Office of Stormwater Management, 10th Floor support activity is going to be covered under this general permit the
P.O.Box 1105 total land area of the off-site support activity and the estimated area to
Richmond,VA 23218 be disturbed by the off-site support activity need to be included in Item
#9.
LINE-BY-LINE INSTRUCTIONS
Item 4:Status of the Construction Activity.
Item 1:Construction Activity Operator Information.
Indicate the appropriate status (Federal, State, Public, or Private) of
"Operator" means the owner or operator of any facility or activity the construction activity.
subject to the Stormwater Management Act and regulations. In the
context of stormwater associated with a large or small construction Item 5: Nature of the Construction Activity.
activity, operator means any person associated with a construction
project that meets either of the following two criteria: (i)the person has Provide a brief description of the construction activity, such as
direct operational control over construction plans and specifications, commercial, residential, agricultural, oil and gas, etc. This list is not all
including the ability to make modifications to those plans and inclusive.
specifications or (ii) the person has day-to-day operational control of
those activities at a project that are necessary to ensure compliance Item 6: Receiving Waters(s)and HUC Information.
with a stormwater pollution prevention plan for the site or other state
permit or VSMP authority permit conditions(i.e.,they are authorized to Provide the name of the receiving water(s)and corresponding HUC for
direct workers at a site to carry out activities required by the all stormwater discharges including any stormwater discharges from
off-site support activities to be covered under this general permit.
01/2014 Page 1 of 2
*sow ‘osore
Hydrologic Unit Code or HUC is a watershed unit established in the gather complete and accurate information for permit application
most recent version of Virginia's 6th order national watershed boundary requirements; and where authority to sign documents has been
dataset. assigned or delegated to the manager in accordance with
corporate procedures.
Item 7:MS4 Information.
b. For a partnership or sole proprietorship: by a general partner or
If stormwater is discharged through a municipal separate storm sewer the proprietor,respectively.
system(MS4),provide the name of the MS4 operator.The name of the
MS4 operator is generally the Town, City, County, Institute or Federal c. For a municipality, state,federal, or other public agency: by either
facility where the construction activity is located. a principal executive officer or ranking elected official. For purposes
of this part,a principal executive officer of a public agency includes:
Item 8: Construction Activity Start and Completion Date
Information. (i)The chief executive officer of the agency, or
Provide the estimated start date (month/day/year) of the construction (ii) A senior executive officer having responsibility for the overall
activity. Provide the estimated completion date (month/day/year) of operations of a principal geographic unit of the agency.
the construction activity.
Item 9:Construction Activity Area Information.
Provide the total area (to the nearest one-hundredth acre) of the
development (i.e.., the total acreage of the larger common plan of
development or sale). Include the total acreage of any off-site support
activity to be covered under this general permit.
Provide the estimated area (to the nearest one-hundredth acre) to be
disturbed by the construction activity. Include the estimated area of
land disturbance that will occur at any off-site support activity to be
covered under this general permit.
Item 10:Common Plan of Development or Sale Information.
Indicate if the area to be disturbed by the construction activity is part of
a larger common plan of development or sale. Larger common plan of
development or sale is defined as a contiguous area where separate
and distinct construction may be taking place at different times on
different schedules. Plan is broadly defined as any announcement or
documentation, including a sign, public notice or hearing, sales pitch,
advertisement, drawing, permit application, zoning request, etc., or
physical demarcation such as boundary signs, lot stakes, or surveyor
markings indicating that construction activities may occur.
Item 11:Stormwater Pollution Prevention Plan(SWPPP).
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(VAR10)prior to
submitting this Registration Statement. By signing this Registration
Statement the operator is certifying that the SWPPP has been
prepared.
Item 12:Certification.
A properly authorized individual associated with the operator identified
in Item 1 of the Registration Statement is responsible for certifying and
signing the Registration Statement. Please sign the Registration
Statement in INK.
State statutes provide for severe penalties for submitting false
information on the Registration Statement. State regulations require
that the Registration Statement be signed as follows:
a. For a corporation: by a responsible corporate officer. For the
purpose of this part,a responsible corporate officer means:
(i) A president, secretary, treasurer, or vice-president of the
corporation in charge of a principal business function, or any other
person who perform's similar policy-making or decision-making
functions for the corporation,or
(ii) the manager of one or more manufacturing, production, or
operating facilities, provided the manager is authorized to make
management decisions that govern the operation of the regulated
facility including having the explicit or implicit duty of making major
capital investment'recdmmend'ations, and initiating and directing
other comprehensive measures to assure long-term compliance
with environmental laws and regulations;the manager can ensure
that the necessary systems are established or actions taken to
01/2014
Page 2 of 2
ALk
-Request for Pre-construction Meeting and Grading Permit
from Albemarle County
Approved Plan Number: WPO- 2 0 (fi 0 0 LI q
Approved Plan Name: i-0 Ff buv1 OLOr ci - 14yAlte p b t
(Plans must be approved prior to a pre-construction meeting.)
Bond approved date: /0 /OS- /ic '
(Bonds
must be approved and posted prior to a pre-construction meeting or permit.)
Responsible Land Disturber:
Print Name:
State Certification Number: 3 560 90
Address ?, 0. oX 1 0 0
City a 1,3(L State 0-4- Zip ZZ�2 C/
Daytime Phone(Y,5(1; 53 ( — /`� / E-maili e eqr a t"f e Gd D(, LGA
Primary Contractor: >,J
Print Name /f k1OIC E,(ca
Address -P.C. ry X ) S 3
City ctiesu t State � T( Zip ZZei2/
Daytime Phone(Y..* C3 / /4// E-mail j e.. r Ot r- i a p/, dory,
Permit Issuance and First Year Maintenance Fees: (Request must include payment)
Total acres proposed to be disturbed is contained on the approved plan and application:
VSMP:
Acres to be disturbed Fee Due at Grading Permit
Less than 1 $63.80
1 and less than 5 $594.00
5 and less than 10 $748.00
10 and less than 50 $990.00
50 and less than 100 $1,342.00
100 and more $2,112.00
For plans exempt from VSMP,VESCP fees were paid with the application.
7/1/14, Revised: 8/29/14 Page 1 of3
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Person(s)to attend the Pre-construction Meeting:
Names(type or print) Firm Contact Number or email
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The second part of the application fee is required to be paid with this request. This fee amount is;
FOR OFFICE USE ONLY Permit Issued Date
By who?
7/1/14,Revised: 8/29/14 Page 2 of 3