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i <br /> � <br /> � BACKWAT�R P62�VEN�101� �3�VOC� �EB�A� <br /> 86VST'AL�ATi0�9 CiiEC�Cf�BS� <br /> ; <br /> � <br /> Installahon Company Name antl Contacl Inlo. �4,�>�l� /J� ! <br /> i��L�N�.F%.� <br /> Date Backwater Prevenlior.deviCe i8�,1'D) ,vas ins�al!ed '� ; � � <br /> � . I� Date Ihis form was compleled,�,J <br /> Inslauat�on Property Owner Nam=aad Conlacl Ir(o���u:,�, � <br /> t•-0.r�c r� <br /> Froperty Address:_I Z I (_.Q 'Qi r�, � „ �� ..—_" ---- <br /> _.�»r�cdc.�, <br /> Pre•InatallaHon Inspection Chechliat: � "- <br /> nrr rt?ms must be checked }'es rn ot�er lor a BWU to he con;idered(or mstaltatron <br /> is!here a basement or le�el ef�e nouse Ihat is at or near assumetl sewer main elevat!on%f�Yes ❑No <br /> Are tne•e fixlure5 in lhe house Iataled Eelcw!he upslream sewer manho�e rim elava�on��Ycs ❑No <br /> Is the side Sewer���nlly UNPROTECTED fmm sewer p�cKups(n�es not have a 6WD installetll��Yes ❑No � <br /> Site Inspection Ch�ckllsf: <br /> Ali dems must 6a cAecked'Yes'hz;ore mspecflon i�cprrde�aC complefe <br /> Vr'as sitie sewer N inxpected hom buildmg lo se�ver rr�;in� (�,Yes [�No Co�d•hvn <br /> Does Side sewer have at feast t',�slope f:cm lhe balltling te sewer main? i�Yes i��'o Descnbe: <br /> Have all b�ildmg sewer dram mnneclions to the s!de se«�er been IdentHed and Iocaled7 �Yes [�No ' � <br /> Have ali p�epenysrorm dreinage conrea�ons Io 1he stdesevrer been identified an�lowred7 �YeS L Ho <br /> Has�roperty heen evaivaled fot drainage de5ciencies vnth find�ngs�ommunicaled to prnpeAy cw�er? �]Yes ❑No <br /> Instellatlon DMails; <br /> iNha�tppe and brantl of BWD was installed at ihis site(Cle,�n Check BWV.Gnndar pump, etc.) (` lpr�.., , <br /> Wh°rs Nas•he dawce Insalled;genera(desc�;pt,on, anarh mapl? ��� ��� <br /> /:���+�s–,:_— <br /> Was?tere anyolher sewer cr storm dr�inage wodt compleled in c��r�uncticn wift,the 8Wp waik��s sn please descr�her <br /> installation Checkllet: �— —'— � <br /> �� , <br /> Are all dow��spouls and�ite drainege di;connecteJ trom upstream of I�e OWD�,A(1 Yas (_'N�� Comments: <br /> Dxs DN'D p;,silioning meel�minimum slope requi2ment uf>1;;? �'Yss �1 No CommeNs. <br /> Car 84VD�e pulled p�l lor inspecf�on antl maintenance aher loosen ng thumb s;rew��C yes �fJo ��--- <br /> fs 04YD lucked Into ihe pro�er pesitinn and thumb:crev�tigMened i (�'YAs �� No ' <br /> C�rGe the dWD cover:irngauon cover(landscao¢ereaj 1tralGr load bear�no tover�anve s�riac:)r access ha�rh(buiiding) . <br /> 4NA5 property Otvner shpwn ihe iocation o(Iha ms�alled BIND� �yes L;No Comments 1 <br /> °toperty Ow��er's Signature. V� �`�- ; <br /> Insfallers Signa�ure — Date I 1-8 /5� ; <br /> Uals:��/ �,d /// � <br /> Revislonr2 '--7'-`�-- I <br /> � F•,day,Septem6er �2, Z014 <br /> S�£��bed 10£b 6SZ 52b�w��.� 50�£T STfi2-82-Ntlf ! <br />