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I <br /> �ackwater Valve Installation Program <br /> Installation Authorization Form <br /> 1 Perrnission W Insoect The Ottiner grants permiss�on to the Cdy ar,d ds contractor to <br /> inspect the plumbmg and drainage of [he Owner's property for Pie purpose of <br /> I determmmg v✓hether a backwater valve should be installed lYe City and Ovmer r:�ll <br /> cooperalz to determine a mutually agreeable time for the inspecaon The inspecUon <br /> is at the City's sole cost. <br /> i2. Backrlater Valve Insfallatwn The City will review the results of the insp�ction and <br /> i v:ill determme�a�hether a backwater valve should be installed By siqning this <br /> I authorizahon form, U�e Owner grants the City and ds contractor permission to instali <br /> fhe backwater valve if Uie City determines that a back�vater valve should be mslalled. <br /> � This installation is at the Cdy's sole cost <br /> I3. S_,te Drainaqe. Ii inspection of the prope�y �dentifies that there are downspouts <br /> I connected ro the side sewer upstream of the proposed backv�ater valve location, lhe <br /> dovdnspouts will be disconnected or re-rouled dov;nstream of lhe backwater valve <br /> By signing this authorization, the Owner c�rants the City and its contraclor permission <br /> to access the Owner's propeny to modily dramage conneclions. Drainage <br /> medifica?�on �s at the City's sole cost. <br /> OWNER(S): <br /> I . �= � �� <br /> �L <br /> `�_) � ��� ���_�4_n.� <br /> Siynalure: Signature <br /> r D ��N N. G A R t-SiaxJ <br /> ✓e�?_A A._C:� R �- 5�rr��J <br /> Pnnted Name Printed Name: <br /> j /���,� G,ea�� �v� io — i � - i y <br /> ` Prinled Address Date <br /> � (��e) .�s�s-iy �3 N �h _ <br /> Phone Number Cmail <br />