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Backwater Valve Installation Program <br /> t„ Installation Authorization Form <br /> 1 Peroiissicn.to Insp?ct The O�:�ner grants oermis��on to the City and ds con'r,,Nor to <br /> mspect the plumbing and drainage of the Jv✓ner's property fur the p�rpose ui <br /> de?e•minmg whether a backwater valve should be ins?alled The City and Ovmer will <br /> coepe�ate to determine a mutually agreeable lime for the inspection The mspechon <br /> �s at ,ne City's sole cost. <br /> 2 BacRwaler Valve Installatio� The Cdy will reviev� the results of the inspeclion and , <br /> wdl determme whether a backwater valve should be installed [3y signing this <br /> aufho�izahon f�rm, the Oe:ner grants the City and its contractor permission to install <br /> the bac'r.watzr valve if the Cdy determmes that a back�vater valve should be installed <br /> Th�s installation �s at the City's sole cost. <br /> 3 S�te Drainage �f msoec!ion of the property iden6fies that there are downspoals <br /> ronnected to the side setieer ups'.ream of the oroposed back�vater valve locatio�, the <br /> don�nspouts v:dl be disconnecte� or re-routed c'ownstream of the backwater valve. _ <br /> 8y signmg this authonzahen, tha Owner grants Ihe City and ds contractor permission <br /> to access the Oavrer's prooerty to modify drainage connections Drainage <br /> •nod�ficatien �s at tl�� City s solc;.ost <br /> OWNER�S): <br /> --- —� �_� —�, j� <br /> ::• r— <br /> ; ,l`� -��,�-;_._ -- ,��l��,L�{`;�1, �?.:t �,,;�� <br /> , , <br /> Si �atare �% Signalure <br /> '`�/J/ 'hC ��C'J�_ �Zln�,�/� �/��."�1,;-/i <br /> Pnnted Name. Printed Name <br /> �S-C?.�, C,;��.t..i� ,��i'� l 0��7 / �� <br /> i'nnted Address Date <br /> _1.CSJ�� J3C7�.3�� � GC� CV9Cc. ` _[�Q f��- ��.iii;�; i � �v!1I <br /> i'hone Numbei E7Ln iI � <br /> � <br /> ' �'.' ` .� �.r� "._ � "i �_1 <br />