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BACKWATER PREV�NTION DEVICE PROGRAM v <br />� <br />,_. <br />7ur �ccnrds mdica;e that a backtva,er prevention dev�ce mus! be �nstalled cn your <br />,.., set•:er connection to comply wdh lhe ne'�:� ordinance !'�.ease help :,� verdy ihat o�.0 <br />- ��nlormat�On is correct by ansr:er�nn t�e (auo�::mc y�es��c�,s aCout ;our prcperty <br />Do you have a hasement7 Yes (� No `� <br />If ye5, dCes it hBVe plumbing 6x�ures is�n<, loilet IIoDr drain eL' �"% Yeti � Nu I� <br />Do you have a hackvialer vaWe on your sewer line� Yes ❑ No � D�n't Know j � <br />Do po� have a gnnder pump in your basement� Yes i] No � Don'I Kno��� [ <br />Name G��LL/ �rvi �`�vEv✓ — ----- <br />Pto�eily �ddrr_ss 3�� � .['�b����_l��Gy�2- --. — <br />f'hone i 72���iS��" �%s'�1 F'hane7 7ZS—�3�_ O�f�9 <br />Finad _— — -- <br />-- - -'. ' .l" � _�1`�'���`�I��(��I1J13����''''', ' <br />'�1;!l�:a'i'���r�il%�., .t.eS�:N.i; .{! ��i.r'.'_�1L•i!��t:.6�{i i�oi <br />