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��Back�nrater Pkewention DevP�� 1�batE Rrogr�lin <br />�� I�ebaCe ApP���'at�gn Farm <br />----------- �- <br />�--- - --- �.,- ��. , -_ <br />c+ropany.Owner N9rtte' � ,� . _�__�:_% �' �-_�" . _-' o -- -' <br />1 �' � <br />luslallutl�r Atldress: � f' = � i � /:ti� °�, � ;f� �� - . <br />..._-_ _ �-•.�._ . . . . ; _=.__.- ' r--=•• `='. <br />Gity �'"%I' G� f�_L-. _ Statc� _[.,' f_ LJ��f r-LI .— -_ _ <br />MoiFinS AJdress 1 ff dldsleny' y •)`� ji� �'� I _ 1 � `/�� �_ - -"�' f- -�.= . _ . . ��.-�- <br />i �r S11t�ti��t'�U _ �ac� � .�_� —r.��k� . -� it= —' <br />� E eii :����;, �; frc,°�_. _<:;;_;'';'l '�:�-_PhonetL'G) � fi.-�j Z��; <br />.� .` ♦ �' _ _I <.0 . <br />�, T��I C�st tn Instal�'tie�me ;finm�cantraoror �Tvelct3): �S �'= ' ".',' - k L . - - - <br />Please verify the4n)IoWir�q; � <br />=j i en. :he awner �t tl�e F�ropext'y �ahe�cs-ths baslnvaterptevonlion•deviee•was installed; <br />'= � 1 LvorKeG wit�. ll�e+:onfiastur (p determiae�Ih81oR.1Gon for the Flao!SwetHi prev9ntion�d6vicee(td <br />u�xt�sar.d tM�t tRo tleclslan cegdrdin� t�zlo��on oftFag dAviQe tves�inine. <br />�&ty ^unUauWr msiruated me hUw to�accoss, inSPa�, ad'd rtsatnFai{� the 4���: ��� . <br />'_; I understentl that I am rospnn6ltite ftx r�amlairling tfie�6aaicvr�tnr�praKenUQn devic� a�t! I{e�ping'� <br />h m go:� �JO�kltl9 Jf[1Bf unleas li Is tr+eidlled�in.(he��ity'ngh[��Way.. � <br />�z' �t; n��li my c•z�ne�ry I will make•potanfral�huyers aware�olttte beckweteP{�[evenBomdeViee erld <br />�� tr,e need to �Fl56ect at�d ma(ntmn it an a re�ui�r bes�.5, _ - '� "j� <br />[ a I am �nabstcty all eR 8�e•necessa .ry papenvor4s�(usa•tfie yellaw RepaCe��bini�l'OheGfcli$t)�, '�';1 <br />. '<I <br />SeteetfromtFzfollowbig: . � �. � , �♦ �•��"`'�;'� . <br />�� ihe cwntraotnr i9enUflad do�vn5pod�s uf �U�er drainage•Ill�es tt�ebWelu connoeted3b my sewer ` • � <br />J Ana (3envear� my tause and'�hedRstalled,tlevice) and rpmo,vod urtarouted fhom. �; �., , ��'j� <br />�;,% Po r�y�Cno�vledg�, �k'Prof��Y I�aS�yo,doxnspo.ut«o1.o,therqm�nag�,l,coon��te¢'to my s�we�.Gne ,�''! <br />�hetwoan �Y heuce anC !he inslelleu da�r._(;): � <br />� :,�+ ^ .� <br />r; Pnere a�R aowrspoutsorolher•tlrai�og�linescon'nectixldartiysewGY9�ne (bc.tween my4iouse: „' .� F <br />andtriawstelleadevioa).lend$rsland.thatloa�Ingth9KeconnQalions�ah�atAs��risk.offl4p��g• ,�:;�{ <br />end � aaxet�llhBt risk. • . .' ��' , <br />- , • '�:i <br />, . � :, <br />, . � � > � :-.;r:; <br />, �-_ - � :'r - /, �%i <br />Slgnaturtl�.,^,,,.,. ,�, ��'� _._..__�-- DBfe �: ,,_, <br />0 <br />9 <br />m <br />..__�._ .�__."'"_`___�_.._ _..._--'—'—��-- <br />. i <br />_ ' '..r <br />� � � _ . ' '..:I <br />. � :t � <br />Y • �� <br />