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HomeMy WebLinkAboutWPO201500015 Application WPO VSMP 2015-11-13 rre' OV A Virginia Stormwater Management Program (VSMP) Application for Albemarle County .: '', Project Name: 6.,,e_ 547.4,. 04, (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes 0 No 0 Is this a revision or resubmission for review? Yes 0 No 0 County File Number: WP' O t c Gt 13 (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. 0 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. C 2-% re Skrlc betnars G G0‘ l//rib- Tax Map&Parcel Print Name of Property Owner S 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 Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name ess PCGnevtC,V1 Address <P O `J d x Co q City CV-vac-to tes.v , A State ry [ Zip '2 2 ',C2 Daytime Phone(+3'V 0240_ —AWL- E-mail `e s s c41(- de t/, Co", 7/1/14,Revised:7/10/14, 1/7/14 Page 1 oft ❑ 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 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;$150 ❑ C. Registration Statement on the official DEQ form. ❑ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. ❑ E. Stormwater Management Plan satisfying the requirements of code section 17-403. ❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings(as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name J,f\ l t M P Address 10\ E. l"'(Q%n S E. 3Cc M City C,trt£af t o ti{/t e State V/k Zip 22°t 0 2 Daytime Phone(`t39 2.2 q--S i ic) E-mail 31/4)5+i el 6 .:e,Ir1 tM? —2.Y\celECt 1(19 Can-) *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO# Fee Amount$ Date Paid By who? Receipt# Ck# By: 7/1/14,Revised:7/10/14, 1/7/14 Page 2 of 2 *01101 '*4111d L' Virginia Stormwater Management Program (VSMP) "Air .123 Application for Albemarle County Vim►,, ��RG1N1A Project Name: Free State Run (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes 0 No Is this a revision or resubmission for review? Yes ® No 0 County File Number: WPO201500015 (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. ® 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. 62-8 Free State Partners, LLC 444/14- 09/18/15 Tax Map&Parcel Print Name of Property Owner ignature 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 Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name Free State Partners LLc Address PO Box 645 City Charlottesville State VA Zip 22902 Daytime Phone(434) 2424802 E-mail jess@reddirtdev.com 7/1/14,Revised:7/10/14, 1/7/14 Page 1 of2 'awe Nye' ®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 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;$150 ❑ C. Registration Statement on the official DEQ fonn. ❑ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. ❑ E. Stormwater Management Plan satisfying the requirements of code section 17-403. ❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings(as-builts)for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name Justin Shimp Address 201 E. Main St. City Charlottesville State VA Zip 22902 Daytime Phone(434) 2275140 E-mail justin@shimp-engineering.com *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO# Fee Amount$ Date Paid By who? Receipt# Ck# By 7/1/14,Revised:7/10/14, 1/7/14 Page 2 of 2 Virginia Stormwater Management Program (VSMP) Application for Albemarle County '►. Project Name: - ef/ _{-e yt (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes 0 No 0 Is this a revision or resubmission for review? Yes 12( No 0 WP0 2015- 15 County File Number:9Dp 2.015O3t I if (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. 0 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. (02.4‘ 'Free— 5k-ak(ParA-ners 111,Z"-- 0 Tax Map&Parcel Print Name of Property Owner Signatur 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 Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name -Tess A c ken b2 C.►'1 Address P CJ, City Ch'rlotieSvItte, State VA Zip 22ck02 Daytime Phone( ) E-mail ` _ss t lie d d t r-dei/_C U - 7/1/14,Revised:7/10/14, 1/7/14 Page 1 oft 0 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 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;$150 ❑ C. Registration Statement on the official DEQ form. ❑ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. ❑ E. Stormwater Management Plan satisfying the requirements of code section 17-403. ❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings(as-builts)for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name 705-Kirk Sh t rvip Address 2.61 F KA.at el ' . c l‘n City Chat IO,fSVt( (e State VA Zip 229 0 2 Daytime Phone( 221-.- 5140i E-mail `uS-'t✓t Q shtnitP -ekrnt✓leeCt-3• )- *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO# Fee Amount$ Date Paid By who? Receipt# Ck# By: 7/1/14,Revised:7/10/14, 1/7/14 Page 2 of 2 Ntli01 Slid Virginia Stormwater Management Program (VSMP) Application for Albemarle County Noc. �jpGIN%P Project Name: •"'(te n (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No 13/ Is this a revision or resubmission for review? Yes Cl- No 0 County File Number: SID Q 2-015 U O k (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. 0 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. l 04A cpAsk. %-sckviecs" 14.4,41a..,- Tax Map&Parcel Print Name of Property Owner ignature 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 Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name te. 54k. Par-610(s 'Address -- Address GQ Sox (QT-S City Ch2r1oHeSk! 1k/ State VA Zip 9d?- Daytime Phone( ) E-mail 7/1/14,Revised:7/10/14, 1/7/14 Page 1 of2 ‘aoloof %411rd Soil sold ❑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 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;$150 ❑ C. Registration Statement on the official DEQ form. ❑ D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. ❑ E. Stormwater Management Plan satisfying the requirements of code section 17-403. O F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. O J. Construction Record Drawings(as-builts)for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name 3tJFY1t�Address 2` 1 . f\uleat y cc k • em City l/A'c]r'tp UQsv 1(lel V Vit- 2 L"()State VA Zip 2_(2_010-2_ Daytime Phone 43i ZZ - 51'tb E-mail 1U5+11(1 btAtilite -tint Y\Qer taco,C„ *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO# Fee Amount$ Date Paid By who? Receipt# Ck# By: 7/1/14,Revised:7/10/14, 1/7/14 Page 2 of 2 Sire *toe Nilo? slot, Albemarle County Engineering Erosion and Sediment Control Plan checklist for plan reviewers 5 Mar 2014 (Use the latest checklist from the Team Services engineering forms site) An erosion and sediment control plan is a document which illustrates the measures used to control erosion and sedimentation during construction. All measures follow the Virginia Erosions and Sediment Control Handbook. Reference key; [Square Brackets] are County Code references, {Curved Brackets} are policy references,and(regular parenthesis)are explanatory. Links to reference documents are provided where possible. Application information: Completed WPO application and fees, with owners signature [County Code 18-32.4.3.2, 18-32.3.9, 17-203, 17-303] Erosion Control plans require a Water Protection Ordinance (WPO) application and original owner's signature. No review is provided without application, owner signature and fees. This is true even for revisions. It is important that the owner be aware of comments and resubmittals, and this is the county assurance. Copies of federal and state permits for any wetland or stream disturbance. (Army Corps, VDEQ, etc) [17-312A,B, 17-319B,D, 17-320C,D, 18-32.1.2, 14-311] Title information: Project title. Titles should be appropriate. It should be an erosion control plan,not a stormwater plan, or site plan, etc. In some cases a WPO package will contain a stormwater plan and a mitigation plan, but they should be on separate sheets with keys and page titles. Professional seal, with original signature and date for professionally prepared plans. Content: The erosion control plan must not contain information regarding permanent improvements that do not also appear on other plans. Erosion control plans are temporary documents that are discarded after projects are complete. Existing conditions plan view information: ✓ accurate current existing topography at the time of submittal, including all existing site features, and any recent disturbances, all at a legible scale L/ date and source of the topographic information: All topography should be at least visually field verified by the designer within the last year A 61 WPO buffer limits; 100' from stream or wetland bank, 200' from reservoirs, or floodplain limit if greater. IA, &. No buffter disturbances without WPO Program Authority approval and a mitigation plan. YL 0- floodplain limits, including 100yr flood limits for any channel with a drainage area of Yl f50+acres. ot, Floodplain undisturbed. Disturbances require a Special Use Permit or Floodplain Development Permit. all existing easements(access, drainage, sight, sanitary easements, etc.)with deed book references, locations and dimensions all critical slopes (typically shaded) XZoning Ordinance buffers shown and protected undisturbed. Disturbances require Planning approval of a waiver. `u N1rr/ Nool Albemarle County Engineering E&SC Plan Checklist Page 2 of 4 Proposed plan view information: Grading: [18-32.6.2, 14-303] proposed topography at minimum 2' contour intervals—tied into existing contours, as well as all proposed site features. (Sites with less than 6' of grade change should consider using smaller contour intervals.) These should agree with other final plans. proposed slopes are all 2:1 (horizontal:vertical) or flatter {Design Manual, section 8} i proposed slopes steeper than 3:1 have low maintenance(not grass) ground cover X` specified on the plan {Design Manual, Section 8} existing critical slopes are not disturbed, unless a waiver or exemption has been granted for the disturbance. [18-4.2, 14-304] Retaining Wall Plans approved. Any walls supporting roads or necessary infrastructure require engineered plans (not generic manufacturer's details) and computations. {Design Manual, section 8} This will also be required where walls are close to property lines and there is the danger of affecting neighboring property, either during construction, with later failures, or with pedestrian or vehicle safety. final contour shapes and slopes ensure no undrained pockets or stagnant pools Narrative: narrative and project title (Narratives are now optional, and not reviewed by the County, other than noting whether they are not seriouly in error, like a boilerplate with another County's name on it.) t)t't)1t'i-1 c1CSCt )24t�11 ct1 tlliLl St;.' t'+,ncl?!lis{ C�i;st'l"i )lit n :?til:l`.'t.'171 :il"c'214 ll t.sl:!Iililt)ii li s1IL tlt'Cl1 11CsCi"3 ion aiCas ltll' oth,.1- :_11titurhat1C('. ��'lal list' t)CI nit 161 i:iit '_1' at C 111<Ui ?i �tf ii! M in RA /,(ltltilf_ tiOlI descrilltiOfN County cticic.ion �a.)n11"i)f lli)tC ',tort1114£tiC[ 1U11O(I t:O?lsiC1C'.t':a[1Ons• this reieC to the stortii'\ ilft` itlan:moment plan tit'ditYlitlt husk) design Cotlll)Utatit)il S illiltlt;ir'. ktr each sediment hasiii :,e(iilllct1t tial) rIe*1f .'t_+i iptitation s1.11t111��tt`_ It}; t.'21i�}l sediment 1;31' E cion and sediment control measures: limits of clearing and grading encompassing all disturbances, entrances, staging and parking areas, areas where sediment laden runoff will cross, or any construction related activities. This must match any landscaping and conservation plans submitted with site j plans a construction entrance (CE)draining to a sediment trap or basin y dust control symbols (DC) '✓ temporary and permanent seeding symbols(TS, PS) ✓ existing drainage divides existing vegetation, with trees to be saved located by drip lines. This must match any landscaping and conservation plans. protection provided for all stages/phase of construction,from initial land clearing to final grades and hardscapes. This is our most important item. Plans which show only • 1401 Nigro SS sand Albemarle County Engineering E&SC Plan Checklist Page 3 of 4 inlet protection on proposed drainage systems, which are only possible to install upon completion of grading, should be denied without further review. no erosion control measures in the way of construction access or grading. Diversion .) dikes or silt fence are not placed in the middle of the site, or through access or grading. Sediment traps are not under or on top of fill material or held up by retaining walls. Construction entrances are not on fill, etc. If the concept for site protection is not / adequate in this regard,further review of the plan may not be possible. V existing soil boundaries are shown with labels. Areas already disturbed are indicated, with constructed fill depth or cut noted. critical erosion areas are identified; areas of constructed slopes, areas near property lines adjacent off-site disturbances are shown with erosion control facilities t/ a stockpile location. where cut or fill balances have a 10,000 cubic yard deficit or more,plans should not be approved without a waste area identified. This must a on-site, or on another approved and permitted site. (Don't make the inspectors chase trucks to find the violation.) L a staging and parking area, or other construction related areas 'rk `�c`�`t') X diversion dikes are used to direct drainage to traps and basins W • silt fence is not used across contours in place of diversion dikes. silt fence is limited to areas of sheet flow with Vo acre per 100ft of level on-grade silt fence. Plans showing only silt fence, without sediment trapping measures, should not be approved unless they meet this criteria and fill dirt is minimal. all swales and low points at the perimeter of the site have a sediment trap or basin. Silt fence in swales is typically not adequate. Check dams do not substitute for traps. If the concept for site protection is not adequate in this regard,further review of the plan may not be possible. -- temporary slope drains (TSD)or diversions are provided to prevent discharge over � disturbed or fill slopes inlet protection(IP) on all inlets okrk ,---- culvert inlet protection(CIP) on all culvert inlets outlet protection(OP)on all outlets ,----- all watercourses are protected and encroachments minimized r \ stream crossing (USC,SC)and diversions are provided at all stream crossings. adequate channels(MS-19)provided for each outfall (see Design Manual for minimum content) all traps and basins are shown with proposed contours. Simple boxes or symbols are not sufficient, in most cases, to determine layout or bond amounts. For each trap; drainage area is 3 acres or less ed for totaldra. ge area,including those for in-line upstream facilities w- . storage is 6 cy or more dry s 'rage is cy or more wet sto : :e is 4' deep or less wet Stora:./side slope is 1:1 or flatter dry storage .e slope is 2:1 or flatter stone weir is 6 I er acre of drainage area embankment and a ne weir height is 5' maximum from outside toe embankment top wi I ks is adequate (see table 16 reference) 2:1 length:width ratio f. flow path ' 'Sad %S. 44r/ simpriAlbemarle County Engineering E&SC Plan Checklist Page 4 of 4 For each basin; (GB 3.14) sized for total drainage area, including those for in-line upstream facilities wet storage is 67cy or more dry storage is 67yr or more wet storage side slope is 1:1 or flatter dry storage side slope is 2:1 or flatter embankment 15' high or less from downstream toe principle and emergency spillways sized per handbook requirements embankment has 1' freeboard during 25yr storm with emergency spillway embankment has 2' freeboard during 25yr storm without emergency spillway trash rack/anti-vortex device specified per handbook requirements riser anchor size specified per floatation computation dewatering device sized for 6+hr drawdown of dry storage: 3"dia. minimum safety fence and signs stating"danger, quick sand, do not enter"provided if near any residential properties, or public access structures and embankment match permanent design for facilities to be converted to permanent stormwater management facilities embankment top width is adequate (see Design Manual reference details) 2:1 length:width ratio for flow path. If necessary, baffles specified only on temporary structures (p.III-79) D tails: (1- a paved construction entrance detail (see Design Manual reference details) for projects in the development areas over 10 acres A a typical section for each temporary channe,i or diversion, referenced from the plan sheets. Existing ground should be shown'at the maximum cross-slope on the plan. details and copies of Program Authority permissions for any variances. Mass or Early Grading: mass grading Planning approval. (T is also called rough or early grading plans which contain only approximate fini • . grades and culverts necessary to grade) Mass grading can only be permitted w• -i'n planned developments where a concept grading plan was approved with the r ening. The agent(Director of Planning)needs to formally determine that • - grading plan is in general conformity with the approved rezoning plan. Otherwise, -, initial site plan needs to be approved prior to issuance of a grading permit. Issuanc- •f a grading permit at the initial site plan stage, as apposed to after final plan appr• al, requires specific approval from the County Engineer. Albemarle C, i—a Community Development Department L• 401 kt intireRoad Charlottesville,VA22902-4596 e:(434)296-5832 Fax:(434)972-4126 -•• Planning Application PARCEL/ OWNER INFORMATION TMP 06200-00-00- Owner(s): FREE STATE PARTNERS LLC Application# WP0201500015 PROPERTY INFORMATION Legal Description I ACREAGE Magisterial Dist.i Rio Land Use Primary Forest Lj Current AFD Not in A/F District u Current Zoning Primary R4 Residential APPLICATION INFORMATION Street Address Entered By Emily Lantz 2 Application Type Water Protection Ordinances 3/17J1015 Project Free State Run Received Date 03/16/15 Received Date Final Submittal Date Total Fees 1700 Closing File Date Submittal Date Final Total Paid 1700 Revision Number Comments Legal Ad SUB APPLICATION(s) Sub.l4 ica4o �:_ C Stream Buffer Mitigation Plan Erosion and Sediment Control Plan s .........gra ..,.G.... .e �_. . a .. - w SRN. .�' `rr. `a4� «...®.k.... .....,.. ..,.. .. �., ........ m....as«.,.a.�" .............w......�..., m.........:w•�.:� APPLICANT/CONTACT INFORMATION ltf Warne Addrr~sa , r Zip �! '. vra_ r ' - .� r 4 x, i � ti � Prannry Contact JUSTIN SHIMP 201 EAST MAIN STREET SUITE CHARLOTTESVILL 22402 4342275140 Signature of Contractor or Authorized Agent Date i , �n ' Virginia Stormwater M''agement Program (VSMP) `�✓'' ', Application for Albemarle County , e', Project Name: free s' ,.-G gm (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No ❑ Is this a revision or resubmission for review? Yes ❑ No ❑ County File Number: (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. 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. � �2- $ ce 5l�+c.cc�1+ne-vs,Lt.c.. .� a e7Z__ 4/0Y Tax Map&Parcel Print Name of Property Owner Sign ure 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 Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name Address City State Zip Daytime Phone( ) E-mail 7/1/14,Revised: 7/10/14, 1/7/14 Page 1 of 2 XB. All Fees [Code section's/II-208] ''''✓ For new or modified plans;Total acres proposed to be disturbed G.21 Aue 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 $1,15.9, $200 5 and less than 10 $3,400 C$T,700 $250 10 and less than 50 $4,500 $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;$150 7(C. Registration Statement on the official DEQ form. JD. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. Stormwater Management Plan satisfying the requirements of code section 17-403. ❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings(as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name 5+CH, 5 ►int,o1 P C Address 2°1. 1 Nlc.'v f, 5k./h City Olavtodfe6v,`Ile. State v144 Zip Z2410 Z Daytime Phone(61311) 7 Z 1.514 c) E-mail T t44v.e$lost f-erl iNcWir+y•COM *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$ )7aD Dat Paid 1)l6 h By who? f! S�G}-Q. Receipt#99 01 O Ck# 102—% By: .DK ��tnpf LLC 7/1/14,Revised: 7/10/14, 1/7/14 Page 2 oft 1 'otkalti Registration Statement 404,00 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 th appmpriate perso associated with this operator.) Name: 1'fe.G 54.4e— ItiW51I.1.-G. , Contact: }� Mailing Address: !�o. 20r4 6H5 City: CJ1c.t'i ies V g'1 le_ State: I A Zip: 72 902 Phone: Email address(if available): Indicate if DEQ may transmit general permit correspondence electronically: Yestg No❑ 2. Existing General Permit Registration Number(for renewals only): 3. Name and ocation of the Construction Activity: Name:and S1Lwk. iG nu y) Address(if available): N City: a.f1O CSW1I . State: VI64%VA_ Zip: 2 ZCIO� County(if not located within a City): 41 bety�,�.vft Co%lv�,` / �/ Latitude(decimal degrees): 38 07 02 46 6 Longitude(decimal degrees): —7g.41571 3B° 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 thet � Construction Activity(e.g.,commercial, industrial,residential,agricultural,oil and gas,etc.): FCSt*v'h') subdN/CS try\ 6. Name of the Receiving Water(s)and Hydrologic Unit Code(HUC): Name: R.VQnnu.. 2ivof- Mew t e.k- Name: HUC: 62.00020404 0 1 HUC: 7. If thedischaarge is 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): CA/01/ 2015— Completion Date(mm/dd/yyyy): v 9/0 1/Z0 11 9. Total Land Area of Development(to the nearest one-hundredth acre): —7.0e1 4Gre.S Estimated Area to be Disturbed(to the nearest one-hundredth acre): 6.44 icitieS 10. Is the area to be disturbed part of a larger common plan of development or sale? Yes❑ NoelSt 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 imprisonmentknowin violations." / Printed Name: 2Wim, Acut1 Title: .)4An 1 0)14/44✓ Signature: 7 �� Date: 5//0 /5- (Please sign in IN his Certification must be signed by the appropriateerson associated with the operator identified Item#1.) P P in 07/2014 Page 1 of 1