Revised CITY DOCUMENTS PROCEDURES AND PROGRAMS - Downspout Disconnection Program

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Questionnaire The Applicant must provide information for each individual downspout on the property. Downspout Downspout2 Downspout3 Downspout Is the downspout currently connected to the City Sewer? 1 ❑ Yes ❑ Yes ❑ Yes ❑ Yes ❑ No ❑ No ❑ No ❑ No If you selected No for a downspout no further information is required for that particular downspout. 2 Why are you applying for an exemption? ❑ Will create a safety ❑ Will create a safety risk ❑ Will create a safety ❑ Will create a safety risk risk ❑ Is not technically risk ❑ Is not technically ❑ Is not technically feasible ❑ Is not technically feasible feasible 0 Both feasible ❑ Both ❑ Both ❑ Both 3 What surfaces are within 6 feet of the downspout? ❑ Grass ❑ Grass ❑ Grass ❑ Grass ❑ Garden ❑ Garden ❑ Garden ❑ Garden ❑ Patio ❑ Patio ❑ Patio ❑ Patio ❑ Walkway ❑ Walkway ❑ Walkway ❑ Walkway ❑ Parking pad ❑ Parking pad ❑ Parking pad ❑ Parking pad ❑ Laneway ❑ Laneway ❑ Laneway ❑ Laneway ❑ City Sidewalk ❑ City Sidewalk ❑ City Sidewalk ❑ City Sidewalk ❑ Swale or Depression ❑ Swale or Depression ❑ Swale or Depression ❑ Swale or Depression ❑ Other, please specify: ❑ Other, please specify: ❑ Other, please specify: ❑ Other, please specify: 4 What is the approximate distance from this downspout to the neighboring property? feet feet feet feet 5 Can the downspout be moved and/or relocated, altered or extended to allow water to discharge to an area that would not create a safety risk? ❑ Yes ❑ Yes Yes ❑ Yes ElNo ❑ No :EEDI No ❑ No If you answer 'No' above you MUST specify why below (at point 6). Use additional pages and attach if necessary. 6 Additional optional comments