2. 
4. Stormwater Utility Credit Application

   THERE IS NO FEE TO SUBMIT THIS APPLICATION - A separate application must be submitted for each facility on a parcel, and the sum of the credit amounts shall not exceed fifty (50%) percent of the fee for the parcel.

   The site and facility information are provided as reference data for staff. IF APPLICABLE, PLEASE ALSO BE SURE TO INCLUDE :

   Drainage Area Map, As-Built Plans, Other Engineering Plans, Maintenance Agreement, Maintenance History, Inspection Checklist - signed and sealed by professional engineer, and Calculations to determine monetary value of Credit.

6. A.) Site Information
8. Property Name
10. Property Address*
12. SW Utility Account Number
13. Tax Map No.
15. Total Property Area (SqFt):
16. Property Area with Treatment (SqFt):
20. B.) Applicant Information
22. Property Owner of Record*
24. Address
26. Email Address
27. Phone #
29. *Applicant Name*
31. Address
33. Email Address
34. Phone #
36. *If applicant is not property owner of record, the Power of Attorney Form is required (Form A-2 from City Plan Review Forms)
40. C.) Licensed Professional (Professional Engineer or Land Surveyor)

42. **This section is required if a Level 2 BMP is installed.**

44. First Name:
45. Contact Name
47. Address
49. Phone
50. Fax #
52. Email Address:
53. Professional License #
57. D). Select Primary Contact Person For Staff:

    1. Owner

    1. Applicant

    1. Licensed Professional
61. E). Stormwater Facility Information

    Please include installed facility information.

63. Type of Facility:*
65. Type of Credit Requested:*

    1. Water Quantity

    1. Water Quality

    1. VPDES Permittee
69. F.) Public Financing Disclosure
71. Was Public Financing used to construct, repair, upgrade, or retrofit the facility?*

    1. Yes

    1. No
73. If yes, please state:
75. Source of Financing:
76. Date Funds Received:
77. Amount of Funds Received:
81. Related Documents to Submit

    Please upload any documents relating to the application here. 

    EXAMPLE: Drainage Area Map, As-Built Plans, Other Engineering Plans, Maintenance Agreement, Maintenance History, Inspection Checklist - signed and sealed by professional engineer, and Calculations to determine monetary value of Credit.

    These documents may also be sent separately to: stormwater@ci.waynesboro.va.us 

83. Additional Document
84. Additional Document
86. Additional Document
87. Additional Document
89. Additional Document
90. Additional Document
94. Signatures
96. If applicant is not property owner of record, the Power of Attorney Form is required (Form A-2 from City Plan Review Forms).

    Please upload document here

98. By signing below you acknowledge you have given accurate information on this application.
100. Print Name*
101. Daytime Phone Number To Contact*
103. Signature of Owner, Contract Purchaser, Agent*
104. Date*
     Date
Leave This Blank:


106. 1. Receive an email copy of this form.
107. Email address

     This field is not part of the form submission.

108. Submit

* indicates a required field