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Application for participation in South Bend's sewer back-up <br />prevention program for the installation of a Basement Valve. <br />Submit this completed application form to: Department of Public Works, Basement Valve Program, <br />County -City Building, 227 West Jefferson Boulevard, Suite 1316 N, South Bend Indiana, 46601. <br />I/We hereby request participation in South Bend's sewer back-up prevention program for the installation <br />of a basement valve. <br />I/We own and reside at this property and the application is for work to be completed at this property: <br />Address: <br />Parcel Number (PIN): (Obtainable from your property tax bill) <br />Telephone: <br />I/We have read the eligibility criteria and declare to meet that criteria ❑ <br />I/We agree to allow a City Inspector make any inspection and or tests on the work completed ❑ <br />By participating in this program the property owner accepts and/or retains ownership, operation, <br />maintenance and replacement responsibility for the backflow device installed and understands that these <br />devices do not guarantee against storm and or sewer back-ups but are installed as an additional <br />precaution. <br />Dated this day of 20 <br />Owner 1 <br />Owner 2 (if applicable) <br />Print Name: <br />Print Name: <br />Middle Initial: <br />Middle Initial: <br />Signature: <br />Signature: <br />Driver's License Number: <br />Driver's License Number: <br />Last 4 digits of Social Security Number: <br />Last 4 digits of Social Security Number: <br />