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Backwater Valve Installation Program <br /> E„ Installation Authorization Form <br /> 1. Permissio� to Inspect The Owner gr:nts permission to the Cdy and its contractor lo <br /> inspect the plumbmg and drainage of the Owner's oroperty for the purpose of <br /> determming whether a backwater valve should be installed The Ciry and Owner will <br /> cooperate to determine a mutually agreeable time for the mspection The inspection <br /> is al the City's sole cost. <br /> 2. [iackwater Valve Inslallalion. The City will review the results of the inspectron anC <br /> �vill deternune whether a backwater valve should be installed. By signing this <br /> authonzation form, the O�ener grants the City and its contractor permission to install � <br /> the oackwater valve if the City determines that a backwater valve shouid be installed. <br /> This installation is at the City's sole cost. <br /> 3. Site D•ainaqe. If inspection of the property idenhfies that there are downspouts <br /> connected to the side sewer upstream of the proposed backwater valve location, the <br /> downspouts will be disconnected or re-routed downstream of the backwater valve <br /> By signing this authonzation, the Owner grenls lhe Ciry and ils contractor permissi�n <br /> to access the Owner's property to modify dramage connections Drainage <br /> modification is at the City's sole cost <br /> OWNER(S): <br /> �4��- — ,/ � <br /> Signature. Sig ture. <br /> �T�`I� Iy���e ile OLso:� <br /> Prinled Name � �'��nted Name <br /> I �i IR �f«.� e_ 101?olz�y � <br /> Printed Address ���� � <br /> yZ�-� ZZ-77$�!' ka�livlcoh a(��vHa�I -Cv� <br /> Phone Number Lmail <br />