Wqia Dpw Form 202 - Hanover County
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4Office Use Only
E & S #:
Plan File Name:
HTE #:
H
C
,
V
ANOVER
OUNTY
IRGINIA
P
W
D
UBLIC
ORKS
EPARTMENT
C
B
P
P
HESAPEAKE
AY
RESERVATION
ROGRAM
Water Quality Impact Assessment (WQIA)
(Pursuant to Hanover County Code Section 10‐43)
General Project Information:
Date:
Project Title:
District
GPIN:
Magisterial District:
Subdivision:
Sec:
Blk:
Lot:
Owner’s Name (s):
Mailing Address:
Business Phone:
Home Phone:
Mobile Phone:
Email:
Resource Protection Area (RPA) Information:
Does the site contain any of the following (check all that apply)?
Tidal Wetland
Nontidal Wetland (connected by surface flow and contiguous to tidal wetlands or water bodies
with perennial flow)
Tidal Shores
A vegetative buffer not less than 100 feet in width adjacent to and landward of the components
listed above, and along both sides of any water body with perennial flow
Resource Management Area (RMA):
Does the site contain any of the following (check all that apply)?
Floodplains
Highly erodible soils (including steep slopes)
Highly permeable soils
Nontidal Wetlands (not included in RPA’s)
Within 150 feet of a RPA vegetative buffer
Required Attachments:
For individual residential lots:
Submit a “to scale” plat depicting the location of all RPA features, 100‐year flood plains, and
wetland on the lot or parcel relative to all existing and proposed developments.
Submit a signed copy, by a qualified professional, of a site‐specific in‐field evaluation and
delineation for perennial flow based on the latest edition of guidance documents issued by the
Chesapeake Bay Local Assistance Department (CBLAD).
For site plans and subdivision plans:
Submit “to scale” field‐surveyed locations of all RPA features, 100‐year flood plains and wetlands
on the site plan or subdivision plan.
Submit a single copy, by a qualified professional of a site‐specific in‐field evaluation and
delineation for perennial flow based on the latest edition of guidance documents issued by the
Chesapeake Bay Local Assistance Department (CBLAD).
DPW PDF form 202
Rev 1/29/2015
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