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� <br /> � <br /> ��C9��l�T"�� 6�R��B�6��'I�N �E�9C� EEN��. ` <br /> g �R4�1'AL.�..Q��6�k'�@ C�ECfCIl�I�T ( <br /> i <br /> .� — ; <br /> Installat'on Co�npany Name and Contaet Info: � � �%� C �'?'`� ��Z� � <br /> ---� 1 �- i <br /> Dale Back�valer Prevention device(8V�`�;�vas inslalled� ' ` Dale this tortn was completed��1,S-.1 S i <br /> ' c_� '��2�} ''82 i� � <br /> Installalion Property Owner Name and CoNacl info: �/i)��� C �'1!� b'-Q, i <br /> Property Address: �`2- ``' � <br /> ; <br /> Pre•I�stallation Inspection Checklis4: ! <br /> All items must be checked'Yes'in order tor a BWD fo be considered for instalfafion ! <br /> is Ihere a basement or level of lhe house lhat is at or r,ear assumed se�ver main elevation7�s ❑No ;, <br /> i <br /> Are there fixlures in the house located below ihe upslream sewer manhole rim elevalion7 es ❑ No + <br /> Is the side sewer currently UNPROTECTED from sewer backups(does nol have a BWD installed)?�'res ❑No ` <br /> Site Inspection Checklisf: ' <br /> I <br /> i <br /> AU 8ems must be checked'Yes'6e�ore inspeclior,rs considered com{Nefe � , <br /> Was side sev+er TV inspeeled(rom building lo sewer main7 D�s ❑No Condilion:��0 v` � �r i <br /> Does side sewer have at least 1%slope from the building lo sev;er main? �'�es ❑No Des be: i <br /> Have all building sewer drain connections lo the side sewer been identifietl and located? [�]-'Yes ❑No <br /> Have all properly slorm drainage connections to the side sewer been identified and localed? [�`res ❑ No <br /> Has piooerty been evalualed for drainagE deficiencies�:�ith 6ndings communicaled lo properlY owner? (�]'i'es ❑ No <br /> Installation De4ails: P P � �_� <br /> Whai type and brand of BWD was installed at this sile(Clean Check BWV, Grinder um , elc. : n�-G��c <br /> Pl -<3-=P j3�.��`�l i _ <br /> Where v�as the device installetl(general description,allaeh ma ? _ <br /> �u_..� +� �c�N�S � � — - <br /> UJas there any other sev�er or slorm drainaye work ompleted in conjunclion vrdh the BWD work? Is so please deseribe:_ <br /> ���_ �. <br /> Instatlation ChechlisQ: <br /> Are all downspouls and site drainage disconnec!ed from upstream of the BWD? �s ❑No Comments:��-� <br /> 6oes 6WD positioning meels minimum slope requi�ement oi>1°u� ��s ❑IJo Commenls: <br /> Can BWD be pulletl out for inspection and maintenance aRer loosening Ihumb screw? [i�`�s ❑No <br /> Is BWD locked into the proper position and thumb screw lightened? �es ❑No <br /> Circle ihe BWD c�ver: irrigalion cover llandscape area)!traffic load bearing cover(dri��e sarface)I access hatch(buiiding) <br /> UJas properly owner shovan the Iocalion of the installetl BNJO? [a'fes ❑No Comments: -- <br /> Property Owner's Sign IJV �% -- Date . �l-1� ' �� - <br /> �•T-- __-- <br /> Installer's Signalure���� _ Date:�_�_ � ^• � <br /> ✓ <br /> � Friday,Septem6er 17, 7_074 <br /> Revizion: 2 <br />