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• utl <br /> Nov.16.2014 01:29 PM PAGE. 1/ 2 <br /> 425-262.5874 P.3 <br /> American Septic e.Sewer <br /> 1 <br /> 1 1 <br /> 1 1 <br /> Backwater Proven on Device Rebate Program <br /> . Rebate • ppllca+tion Form <br /> Property Owner Meme: <br /> Instellatton Address:_ 2-2 2.- - <br /> Ci <br /> A-__:-.L.-/e7- (s'/ / BtaM: `�'� zip:___ lJ � / <br /> City: <br /> Meiling Address(If dMlereny: STEVE W RI I AM S. . <br /> State. PAH 7t ,. 0-196STS 8� <br /> �� 6321, Y NNWS`1�00 IVA 98036 <br /> Email: more: rcr)� <br /> Total Cost to Install De�vioe(from contractor oiae):$ 22 `f `t g - ,Z' <br /> Please verify the ell wing: <br /> 13:141" owner of the property where the• • • ._ prevention device was installed. <br /> . c--corked with the contractor to determine the,--•don for the backwater prevention device end <br /> understand that the decision regarding tee • lion of the device was mine. <br /> IE • «.ntractor inalructed me how to access,i • pent,and maintain the device. <br /> y I un rstand that I am resoons%le for manta ' ••the backwater prevention device and keeping <br /> It good wonting ostler,unless It is Installed the city right-at-way. <br /> if!sail my property,I will make potential bo were of the backwater prevention device and <br /> tr •ed to inspect and maintain it one reg , battle. <br /> 1 am enclosing all of the necessary Pape • (use the yellow Rebate Submittal Checklist). • <br /> Therste from the fallowing: <br /> e oneactor identified downspouts or otti• drainage Il nos that were connected to my sewer <br /> 1' (between my house and the installed dev e)and removed.or rerouted <br /> To my knowledge my property hes no•• ••uts or other drglnage connected to my sewer the <br /> (between my house and the Installed device).1 <br /> 0 There we downspouts orattier drainage I • connected to my sewer line(between my house <br /> and the inetaa11ed device).I understand that ng these connections creates a risk of flooding <br /> end I accept that risk. <br /> 16 <br /> / : <br />