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l <br /> i <br /> American Septic&Sower 425-252-$074P.D3 <br /> 3 <br /> 7 <br /> Backwater Prevention Device Rebate Program <br /> Rebate Application Form <br /> � 1 <br /> 1 <br /> 2 <br /> Property Owner Name: t <br /> Installation Addieas: <br /> Civ-L-� /tom State' _Zip: <br /> Mailing Address(if diluent): p <br /> cid; i'P/><Q state: Zip: 0 <br /> Email: _—Phone:( ) t <br /> t <br /> Total Cast to InaWl Device (from contrectarlvcice):$ <br /> ( <br /> t <br /> 3 <br /> Ploaso verify the following: <br /> am the owner of the property where tree backwater prevention device was instaNd, <br /> I,nrori ec3 vvlth the contractor to dkerrntne the location for the backwater prevention device and <br /> understand that the decision regarding the ibcatlon of the devise was mine. <br /> i <br /> My contractor Instructed me how to aCMS,inspect,and maintain the devise, <br /> I understand that I orn responsible for maintaining 11he backwi t+er prev"on device and keeping <br /> i2 in good working order,unless it is installed in the city right-of-way. <br /> s <br /> If I sell my property,t will make potsntlat buyers avmre of the backrnrater pnuventton davits and x <br /> the need to Inspect and maintaln it on a regular basis, t <br /> t <br /> I am enclosing ail afthe necessary paperworl;(une the yellow RobvW Submittal Chacklist)- <br /> Select from One lbir*Wing: <br /> Tse eontroctor idenlified down®pouts or other drainage limes that were connected to my sewer <br /> line(batvvean my house and the installed devlce)and removed,or rmro�ftd them. <br /> To my knowledge,my property has no dovinspouts or other drainage connected to my sewer tine <br /> (between my house and the installed device). <br /> [] There are downspouts or ether drainage lines connecteo to my sewer line(bstween my house <br /> and the Installed device). l understand that leaving these connacGons creates a ristt of flooding <br /> and i accept that risk. <br /> Sr�nx rm Q----Fate 1 <br /> a <br /> 3 <br /> 3 <br /> 1 <br /> i <br />