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---------- - �(�C�(��_��� <br /> NOV 0 4 2014 � <br /> PUfi1.IC 'J✓O;ZKS <br /> Backwater Valve Installation Program <br /> Installation Authorization Form <br /> I1. Permission to Inspect The Owner granls permission to lhe City��ndursosetofclor lo______ _ <br /> � inspect the plumbing and dramage of the Ovdner's property for the p p <br /> aooperate ioVdetehmine�a mutuaely ag eeablel�time for the tl pect olny. The Ospectionl <br /> � is at the City's so'e cost <br /> I Z �ackwater Valve Installation The City vdiil review the results of the inspection and <br /> will determine whether a backwater valve should be installed Eiy sigm,ng this <br /> I authorizalion form, the Ovdner grants the Clty and its contraclor permission lo install <br /> I the backwater valve ii the City determines that a backwaler valve should be inslalled. <br /> This inslallation is at the City's sole cost I <br /> y3. Site Drainaqe If inspection oi the property identifies that there are downspouts ; <br /> I\ connected to lhe side sewer upslream of the proposed backwater valve location, the <br /> � dov.�nspouts will be disconnected or re-routed downsiream o(the �ack�vater vaive. <br /> tt By signing this authonzation, the Owner grants the Gty and its contractor pennission � <br /> I to access the Owner's property to modify drainage connections. Drainage <br /> Imodi`catio^ is at t�e Cily�s �cle c^s!. I <br /> � <br /> OWNER(S)' ; I <br /> ���'/ � �/� � ------- ----------- <br /> � Signature. <br /> SignaWre: <br /> 1 _ �`�V�-=�2- —�/��� Prinled Name �- — �- I <br /> I Prinled Name: � <br /> ; ( S 32 G,�n�%� �1,��___ ---='-f�z 'v__ --- <br /> � Date <br /> Printed Addiess <br /> D r�l l�Jcl �i,T�Fln��c�1tK2'�, (���'11 <br /> � _�(�_�L°�- 6 GZ.g---- F,;,,�� - �--- <br /> Phone Numher <br /> � <br /> i <br /> 1 <br /> �I <br /> f <br /> i <br /> � � ,� <br />