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BACKWATER PREVENTION DEVICE PROGRAIJI <br /> Our records indicale that a back�vater orevenlion device must be instade� on your <br /> sev:er connedion to comply wdh the ne�a� ordinance Please help us veri(y that our <br /> intormation is correct by ans�vering the follov��ng questions about your property <br /> Do you have a basement7 Yes I�(I No [j <br /> T� �j/ <br /> If yes, does it have plumbing fixlures (sink, toilet, (loor drain, elc )� Yes 1!J No [j <br /> �f <br /> Do you have a back�vater valve on your sc�ver hne? Yes � No [� Don't Know ! ; <br /> Do you havc a grir.der pump in your basement? Yes � No y' Don t Knov+ ❑ <br /> Name _.��(.c!/•C/���/✓ '�— <br /> Property address �[ v�'��`� �v v"� <br /> Phone 1 r��� �/ v�l_.l--� Phone 2� . - --- ----- <br /> Ern,�il �(�/1_q�/��"✓ � �U! • G�M _ <br /> :/ — — — <br /> i �� <br /> -� ------ . 1'IY, -Y" --. . <br /> ,AJ.`WJI,'A ;�.Y.:Ji��S. ����,i. i • .�:/d.:d{�_ 4..k � <br />