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� f-' ` r--' r(_ _,(_', <br /> �jL���li�i�J�� I <br /> � oct t , L� <br /> 4 20,4 �, <br /> Backwater Valve Installation Pro_gram� `;, iP��s <br /> Installation Authorization Form <br /> 1. Permis�ion to Insoecl. The Ovener gran!s permission to the City and its contractor to <br /> inspect the plumbing and drainaoe of tF.e Owner's property for the purpose of <br /> determining �vhether a backwater valve should be instalied The Gry and O�vner will <br /> cooperate to determine a mutually agreeable time for the inspection. The inspection <br /> is at the Ciry's sole cost <br /> 2 Backwater Valve Installation. The City will reviev�the resuits oi the inspec;ion and <br /> will determine whether a backwater valve should be inslalled. By signing this <br /> authonzation form, the Owner grants the City and its contractor permission to install <br /> the backwater valve if the City determines that a back�vater valve shouid be installed <br /> This iostallation is al the City's sole cost. <br /> 3 Site Drainaae If inspection of the property identifies that there are downspouts <br /> connected to the side sewer upstream of lhe proposed backwater valve iocation, ihe <br /> downspouts will 6e disconnected or re-routed do�vnsiream o(the backwater valve <br /> By signing this authorization, ihe O�vner grants the Cily and its contractor permission <br /> to access the Owner's property to modify drainage connections. Drainage <br /> madifcatinn is at the City's snle cost <br /> IOWNER(S): . <br /> ��.�t� �.��- -�c - - � <br /> y� �- __ c�c�:� � � :.L��.<��-r�,r-- <br /> Signature. / SignaturQ! �, <br /> /' U <br /> ����.�,� � .)/4�rn�i�.�-�•. �I, / � � ����-1—`-J�!/��%� <br /> Piinted Name: Printedv� <br /> � (��7� Ll- �' �� e �C� 7� �O/fT <br /> �-�`� <br /> � � <br /> Printed Address ���yd l �a�P <br /> � <br /> �f?-°� - 2'� � - l�� �? cl,,�fUn._s �c �� Lwz�� c 1D1�'�'/:<c�i�� <br /> Fhone Nur�ber Email <br />