AFFIDAVIT FOR DAM INSPECTION WARRANT Commonwealth of Virginia VA. CODE � 10.1-610 The undersigned Applicant states under oath that: 1. The Soil and Water Conservation Board has been refused admittance to the property located at ............................................................................................................................... to DESCRIPTION/LOCATION OF PLACE TO BE INSPECTED AFFIDAVIT FOR DAM INSPECTION WARRANT Applicant: ..................................................................................................................... NAME inspect a dam located on that property. 2. Currently, the dam located on the above-described property is not known to be safe. The facts to support these statements are as follows: ..................................................................................................................... TITLE ..................................................................................................................... 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 __________________________________________________________ MAGISTRATE FORM DC-378 MASTER 11/06 American LegalNet, Inc. www.FormsWorkflow.com