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47r <br /> BACKWATER VALVE INSTALLATION PROGRAM <br /> INSTALLATION AUTHORIZATION FORM <br /> 1. Permission to Inspect. The Owner grants permission to the City and its contractor to <br /> inspect the plumbing and drainage of the Owner's property for the purpose of <br /> determining whether a backwater valve should be installed. The City and Owner will <br /> cooperate to determine a mutually agreeable time for the ins ection. The inspection is at <br /> the City's sole� /q o <br /> cost. T + �- Lw - ,c . d jc( 6i. c-.;. C Ca <br /> tkaih <br /> 2. Backwater Valve Installation. TheCity will review the results of the inspection and will <br /> determine whether a backwater valve should be installed.By signing this authorization, <br /> the Owner grants the City and its contractor permission to install the backwater valve if <br /> the City determines that a backwater valve should be installed. This i stallation is at t <br /> City's sole cost. — Xitit ' O <br /> �� r?i;.�r�! Get- <br /> _ <br /> 3. Site Drainage. If inspection of the property identifies that there are downspouts connected <br /> to the side sewer upstream of the proposed backwater valve location the downspouts will <br /> be disconnected or re-routed downstream of the backwater valve. By signing this <br /> authorization, the Owner grants the City and its contractor permission to access the <br /> Owner's property to modify drainage connections.Drainage modification is at the City's <br /> sole cost. <br /> t ,,,,, i <br /> -//1- , Ik <br /> Signature: Signature: <br /> \11-1PIE1( if 41/7 _,/oa,y2(bes- <br /> Printed Name: Printed Name: <br /> 5 "'7 Wel-ri2or,e tVe le evey-, ?"---60714 <br /> PrinteddaAddresss'��} o <br /> �/ <br /> 5 <br /> Phone Number e p✓, 2,C, % '� do...0K/ <br />