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Home My WebLink AboutWPO201500083 Application 2015-10-21 '- , ��OF At Virginia Stormwater Management Program (VSMP) ��g' s Application for Albemarle County �'�RGItiF� Project Name: S".l" j .. (The name should he the same as it appears on plans) Is this an amendment to an approved plan? YesA, No ❑ Is this a revision or resubmission for review? YesX No ❑ County File Number: li(JPt 2 e 150 0 08 (to be provided by the County for new applications) The following are required elements of new applications`from code section 17-401]. For revisions or amendments,please indicate which items are being amended. Signatures must be provided for any submission. X.A. Signature of the Property Owner for each parcel: (Required with every submission cr revision, NOT TO BE SIGNED BY AN AGENT OR CONSULTANT) By signing this application as the owner, I hereby certify that all requ' ements of these plans and permits will be complied with, and I have the authority to authorize the land distur• activities and development on the subject property. I hereby grant the County of Albemarle the right to en on roperty as requir d to ensure compliance with the approved plans and permits. '31-2/A3 C C 1/5-1/& Tax Map&Parcel Print Name of Property Owner Signature of Owner Date y`, LL 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 qf L C _ Address Z 9 s 6/4 72 0/SOLi, 0 City 4-/J VL SV/L.�..( State VA Zip 7213 CxM Daytime Phone ( ) E-mail 7/1/14,Revised: 7/10/1/-, 1/7/14 Page 1 of 2 l l i+ areCc riCommunity MclntireRoad Charlottesville,VA229132-4 Voice:(434)296-5632 Fax:(434)972-4126Planning Application PARCEL OWNER INFORMATION TMP 03100-0O-0O-021AO Owner(s): 4F LIC Application# WP020150 083 PROPERTY INFORMATION Legal Description !ACREAGE Magisterial Dist 1RD Land Use Primary Industrial E] Current AFD I Not in A/F District tract Durrant Zoning Primary Light Industry LL M _ __.._ [APPLICATION INFORMATION Street Address 411 REAS FORD RD EARLYSVILLE,22936 Entered By i Jud `Martin nr Application Type later Protection Ordinances Project Eari<ysville Business Park- VSMP Received Date 10/21/15 Received Date Final Submittal Date 10/26/15 Total Fees 1350 Closing File Date ( Submittal Date Final Total Paid 1350 Revision Number Comments} ........_ .. _ _. Legal Ad SUB APPLICATION(s) Type Sub icatio Comment Stream Buffer Mitigation Plan 10/25/15 Erosion and Sediment Control Plan 10/26/15 stot a n /Bl! P P /2 x P1 APPLICANT/CONTACT INFORMATION t t est t Zip Phone i a} a LLQ EAt S rtLLE ROA€1 MLLE 6 Prima Cortzct MERIDIAN PUNNING GROUP '1417 SACHEMMM PLACE,STE,2 CHARLOTTESVILL 229014348.95012 �.....i . Signature of Contractor or Authorized Agent Date Virginia Stormwater Management Program (VSMP) "AM% cW74,1-i Application for Albemarle County Avert A 0 / it I r- Project Name: 1 vZ„, i 1 c. (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ;4 No 0 Is this a revision or resubmission for review? Yes 0 Ne,g County File Number: lAJP0-2a9C-3 J (to be provided by the County fOr new applications) The following are required elements of new applications[from code section 17-404 For revisions or amendments,please indicate which items are being amended Signatures must he provided fOr any submission. 15X 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 distFbing activities and development on the subject property. I hereby grant the County of Albemarle the right to • ter)upon te propert,•1.s r,quired to ensure compliance with the approved plans and permits. 3/ —2/A F4 4 C, d ( Tax Map& Parcel Print Name of Property Owner Si, a e of ler / date / Tax Map& Parcel Print Name of Property Owner gnature 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 /14, ciZiP)/9tj P4 X M,00,03/fd: Address / / ;44 6‘ 5-7-4 _ city_GiJ44„Lari: 3-1/74,1,6, Stale y() Zip Daytime Phone( 'Tr) ff5Z—O/1-t E-mail 72,1/4 4,471 EX law/A/476: 7/1/14, Revised: 7110/14, I/7/l 4 Page 1 of 2 XB. All Fees [Code section 17-208] For new or modified plans; Total acres proposed to be disturbed I 31 ACR '3 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 $ ,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; $150 X C. Registration Statement on the official DEQ form. RI D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. X E. Stormwater Management Plan satisfying the requirements of code section 17-403. g F. Pollution Prevention Plan satisfying the requirements of code section 17-404. g G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. l,/JA ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. l,Jii4 ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. /dip ❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the pl��anpppreparer, consultant or agent) //rr Print Name jj ✓M 1 dA pIv I ��f 6eoUP L.ti , Address �1 l 3 S A C..l-i PLACE City Gti i t2 WT` 'ad P LL State VPS Zip 2-7,901 Daytime Phone(tag) 12! E-mail +(v\ller rldios') ()lbe .corn *When applications and plans are reviewed,but not approved, and a response to comments is not received within 6 months from the date of county comments, the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. (� FOR OFFICE USE ONLY WPO# 61015- O [� Fee Amount$rgS .CA Date Paid IN"�I ISThy who? M.••er'i di c" Receipt# t 01 " 1O Ck# A S 3 By: a_ P 6-ro w10, t..t_ 7/1/14, Revised: 7/10/14, 1/7/14 Page 2 oft 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: NGT Nvjx1L1Oi?1:6 ear T1J1S --r)iv% Contact Mailing Address: City: State: Zip: 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): 3. Name and Location of the Construction Activity: Name: EVnLYSY/LLE MAI krir rr /'"O?2. Address(if available): 39 (Peas 1 re) goad City: EA/l yr 1.4 l i e State: V A Zip: ZZy 3� County(if not located within a City): Al !.d E)V )0 n• L C Latitude(decimal degrees): ° 36 , I LI 31'1 Longitude(decimal degrees): — 8• T • Name and Location of all Off-site Support Activities to be covered under the general permit: Name: /1/./4 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.): carr/ E7ZG/10 Lr 6. Name of the Receiving Water(s)and Hydrologic Unit Code(HUC): Name: South Fork., taikP r Name: tJo -k R4rIG R1v& 1A IQ)Veer HUC: J Ra$ HUC: J R t I 7. If the discharge s through a Municipal Separate Storm Sewer System(MS4),the name of the MS4 operator: 8. Estimated Project Start and Completion Date: Start Date(mm/dd/yyyy): f � 2 p/ S Completion Date(mm/d(1/yyyy): 10/0S / 'VO l lQ 9. ' Total Land Area of Development(to the nearest one-hundredth actA): 2,1:.i0 A Estimated Area to be Disturbed(to the nearest one-hundredth acre): e ‘12 Ac-e ES 10. Is the area to be disturbed part of a larger common plan of development or sale? Yes ❑ No M 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: /V/fi Title: Signature: Date: (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