Project Address___________________________________Tax Parcel ID# (TPIN)____________________________
Joint Permit Application # (If Applicable):___________________Date of this Application:_______________________
Owner________________________________________________________________________________________
Owner Address_________________________________________________________________________________
Owner Phone___________________________________Owner Email_____________________________________
Applicant _____________________________________________________________________________________
Applicant Address ______________________________________________________________________________
Applicant Phone_________________________________Applicant Email___________________________________
Project Description______________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(1) What type of vegetation exists at the project site?___________________________________________________
_____________________________________________________________________________________________
(2) How much of number one (1) above will be removed as a part of this project (if applicable)?__________________
_____________________________________________________________________________________________
(3) Attach a mitigation plan for number two (2) above, and indicate below the provider of technical advice for the
project, to include the mitigation plan:
☐ Shoreline Erosion Advisory Service ☐ Virginia Institute of Marine Science ☐ Other (Describe Below)
_____________________________________________________________________________________________
(4) How will the project site be accessed? ☐ Land ☐ Water
(5) What type of equipment will be used in the 100’ Resource Protection Area (RPA)?_________________________
_____________________________________________________________________________________________
(6) What materials will be stored in the 100’ RPA, and for how long (if applicable)?____________________________
_____________________________________________________________________________________________
(7) Which parts of the 100’ RPA will be disturbed? ☐ Landward 50’ ☐ Seaward 50’ ☐ Both
(8) How many square feet of disturbance will result from this project? ☐ <2500 ☐
≤ 5000 ☐ >5000
(9) How many square feet of development will result from this project? ☐ <2500 ☐ ≤ 5000 ☐ >5000
By signing below, you certify that all components of and attachments to this application are true and inclusive of
all details of the proposed project at the property/properties in question, and you certify that all removed vegetation
removed from any and all disturbed areas that might result from this project shall be replaced/ restored in accordance
with the Riparian Buffers Modification and Mitigation Guidance Manual.
_____________________________________________________________________________________________
Applicant/Owner Signature Date
TOWN STAFF ONLY
☐ WDF/Shoreline Stabilization
☐ Minor ☐ Major
Zoning Permit # or Zoning Permit Waiver Approval Date for the Project Requiring this WQIA:____________________
Conditions/Explanations/Notes_____________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Town Staff Signature (for John Settle, Community Development & Planning Director) Date
2020-06-23 Application Version
TOWN OF SMITHFIELD
310 Institute Street, PO Box 246, Smithfield, VA 23431
Tel: 1-(757)-365-4200 Fax: 1-(757)-357-9933
www.smithfieldva.gov
WATER QUALITY IMPACT ASSESSMENT (WQIA) APPLICATION
