City of Madison Engineering Division Backwater Valve Eligibility Survey

1.Please provide your contact information for potential follow-up questions from City staff.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2.Is this property located in the City of Madison?

Yes

No

3.Is it a single-family or two-family home?

single-family household

two-family household

more than two-family household

Other (please specify)

4.Do you own this property?

Yes

No

5.Was the house built more than 5 years ago?

Yes

No

Other (please specify)

6.To your knowledge, does the property have an existing sewer backwater valve?

Yes

No

I don't know

7.To your knowledge, have you ever experienced a sewer backup in your basement?

Yes

No

I don't know

8.If you have experienced a sewer backup in your basement before, please provide how many backups you have experience and what year(s) these occurred.