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i <br /> 1 <br /> ; <br /> �.�Ch'�ATEI3 P�tEVERITIOiL° ��\OiC� FIP�AL � <br /> . � i�9S�'ALL.A►T'i01� CE��CKLiS�' i <br /> ; <br /> i <br /> a i <br /> Instaliation Company Name and Conlact Info:,�1�d� � �•J�� �� ���'(t.(i'� i <br /> Date Backwetot Pravenlion device(B�h'D)v:as insfalled: ' ?. 3 S Date ihis form was wmplefed: `'�%E I S !I <br /> Inslallation Prcpedy 0wner Plamo and Confacl lnfo: S�Li Y IC�t (A' I°UGVtft�� ��Ll.��J l ('Li�� 'ZGyo7E�, �( U'U ! <br /> Property Address: � �1 �I iY1 L' .�}' C'1JL'V�.�I � Il)/1-�$ A� _ I <br /> Pre•Installation Inspection ChecklisL � <br /> AO items must 6e checked'Yes'in ordcr for a 8WU 10 6e considered for instalfatior� } <br /> Is Ihere a basementor lovel of lhe house Ihat is at or near assumed sewer main elevafion?�'Yes ❑No � <br /> � <br /> Are there 6xtures in tha I�ouse iocaled below the upsiream see�er manhole rim elevalionl�'�i'Yes ❑No R <br /> Is fhe side sev�er currently UNPROTECTED trom seerer 6eckups(does not have a BWO installed)?�Yes ❑No � <br /> Slte Inspection Checklist: � <br /> All iters musf 6e cher.ked 'Yes'be%re inspeclion is considered complela <br /> N'as side soiver TV inspected from huilding to sewer main9 �Yes ❑No Condilicn: E�:O f <br /> Does side se�:�er have at least 1%stope from the building!o sewer main9 �]Yas ❑No Descri6e: <br /> Have all buiiding se�.�er drain connections to the side sewer been idenlifed and localed? �Yes ❑�o <br /> Have all proporty storm drainage connections tc lhe slde sower 6een ider.,5ed ard localed? (-}'�-Yes ❑No ' <br /> Has property 6ean avalualed tor drainage deficiencios wilh findings communic�ted to property o�mer? ,�Yes ❑No � <br /> Instellalinn�etails. � <br /> What lypo and brand of BWD was Instelled at Ihis site(Clean Check BWV,Grinder pump,etc.): C,�f=+-����'C��'�L'G�- ; <br /> �A'here�vas tho dovice inslalied (general description,altoch map)7 G��-"����Ll�f C� �lU 1�7E' � <br /> i <br /> bVas there any ofher�e:ver or slorm drainage v�ork compleled in conjunclion�n�lh fhe B�ND tvork?Is so pleaso descri6e:^ i <br /> � - * IrCf� l�r'.l,l.� C� I P(� L.i Y��c:�' il) V�ilc°u� ;ytt)(?�� �.{�-�('. <br /> Insfallation Checklist: � <br /> Aie oll do���nspouls and site dranage disconnoatod from upslruam of Ihe BN'D? �YF?5 ❑ Mo Commonts: ' <br /> Does�WD posilioning meats minimum slope requirement of>t%7 �Yes ❑IJo Comments:__ � <br /> Can[3WD bo pulled oul(or inspec6on and maintenance after loosening thumb scro�v? ��-Yes ❑No ' <br /> Is BWD lockecf inlo Ihe prpper�o�ition and tiwmb screw lighlened9 �Yos ❑No <br /> Circle the B�VD cov�itrig�tion�.(Mndscape area)1 Ua(fic load heanng covor(d�ive surface)1 acc�ss hatch(FuildingJ � <br /> Was property ov+ner shorm Ihe location of lhe installed 84t'D7 ��Yes ❑No Comments: �_ � <br /> /� I ,�i1 � y �� � �/� / i <br /> Properiy O+mer's Signature: i'��/�V✓'"� � Dalo:� �l ; <br /> Inslaller's Signalure: ���—�---�_ �-��'-' Dale:�.�-��lS ! <br /> i <br /> Revision:2 1 Friday,Seplember 12,201-0 i <br /> � <br /> I <br /> � � <br /> _-- - � � — ' . I <br /> i <br /> • i <br />