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����o��o o�� <br /> c�� st�i� «��r.�cs <br /> Backwater Valve Installation Program <br /> Installation Authorization Form <br /> 1. Permission to Inspect. The Owner grants permission to lhe Crty and its contractor to <br /> inspect the plumbmg and drainage of lhe Ov:ner's property for the purpose of <br /> determining whether a 6ackwater valve shouid be installed. The City and O�vner will <br /> cooperate to determine a mutually agreeable time for the inspection. The inspection <br /> is al the City's sole cost <br /> 2. Backwater Valve Installation. The City will review the results of the inspection and <br /> �vill determine whether a backwater valve should be installed B/ signing this <br /> authonzation form, the Owner grants the City anu its contractor permission to install <br /> the backwater valve if the City determines that a backwater valve should be installed <br /> This installaGon is at the City's sole cost. <br /> 3. Site Dr.�inaqe. If inspection of the property identifies that there are downspouts <br /> connected to [he side sewer upstream of lhe proposed backwater valve location, the <br /> downspouts will be disconnected or re-routed downstream of the backwater valve. <br /> By signing this aulhonzation, the Owner grants the City and its contractor permission <br /> to access the Owner's property to modi(y drainage connections. Dramage <br /> modifcation is at the City's sole cosl. <br /> O ��5,. - � - <br /> �X `� - �� <br /> Signature: n u e. <br /> l�.��� ��1.�✓ _ Ma..y�R,+���nd-e�,�_ <br /> Printed Name Pnnted N me <br /> 1� <br /> �y�� C ►u+�i�v-�� - - __ �D ��-�_--- <br /> Printed Address Dale � <br /> /�.t �ell Qq�„�l , l� <br /> ya-S- R�- sSqOL�ke� �� 2�I a . c�l I �yma�l•�vn�t <br /> Phone Number Email v <br /> ��-5- s��� ss�� � �� <br />