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City of Modesto House Sewer Line Repair Cost-Share Program Application to Participate I/We are requesting to participate in the City of Modesto House Sewer Line Repair Cost-Share Program (CSP) for repair of the house sewer line in the public right-of-way. I/We are the legal owners of the following described property, which requires a repair of the house sewer line located in the public right-of-way: Site Address: Owner/Applicant’s Name: Mailing Address: Telephone: (Home) (Work) Email: I/We are requesting the following option for cost sharing offered through the program: ☐Reimbursement option ☐ Loan option (not available for a “Clean-out Only”) AS APPLICANT(S), I/WE AGREE TO THE FOLLOWING TERMS: I/We understand and agree that this application may be refused if it is determined that any of the following situations exist: 1. The property is not a residential property 2. The repair or replacement work is not in the public right-of-way, or 3. The work is not to be completed by a Class A General Contractor or a C-34 Pipeline Contractor, or 4. All necessary paperwork was not submitted to the CSP Coordinator and approved prior to the start of any work. I/We agree that the City of Modesto will provide financial assistance through reimbursement and/or a loan for the cost of the repair to the house sewer line located in the public right-of-way. If the loan option is selected, I/We agree to pay the required fees for establishment of a loan. I/We agree that any remaining costs for the repair in the public right-of-way is at my/our expense. I/We agree that the total cost for any repair of the house sewer line located on private property is at my/our expense. I/We understand that the Section 5-6.309 of the Modesto Municipal Code states: “Each user shall be responsible for the construction, maintenance and repair of his or her house sewer line. Each user shall be liable for damages which may result to the sewage system from his or her failure to keep his or her house sewer line in good order.” I/We agree to the above conditions: APPLICANT: (Signature) (Signature) In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at SIGN