AFFIDAVIT FOR DAM INSPECTION WARRANT Commonwealth of Virginia VA. CODE § 10.1-610 AFFIDAVIT FOR DAM INSPECTION WARRANT The undersigned Applicant states under oath that: 1. The Soil and Water Conservation Board has been refused admittance to the property located at ............................................................................................................................... to inspect a dam DESCRIPTION/LOCATION OF PLACE TO BE INSPECTED Applicant: ..................................................................................................................... located on that property. NAME 2. Currently, the dam located on the above-described property is not known to be safe. ..................................................................................................................... TITLE The facts to support these statements are as follows: ..................................................................................................................... ADDRESS ..................................................................................................................... ............................................................................................................................................................................................................................ [ ] Continued on attached sheet I request the issuance of a dam inspection warrant to enter the above-described property to perform an investigation, test, or other action to determine whether the dam located on such property is safe. ................................................................................. __________________________________________________________ TITLE OF APPLICANT SIGNATURE OF APPLICANT Subscribed and sworn to before me this day: ................................................................................. DATE AND TIME FORM DC-378 MASTER 11/06 __________________________________________________________ MAGISTRATE American LegalNet, Inc. www.FormsWorkflow.com