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i <br /> �ACKViIATE� PRki��N�60�fV D�VICE FiNAL <br /> EPJSTALL�►T'I�N �IiEGF(LIS� <br /> �G ^r `�"�d� �Z-�'� L LG: � <br /> �ri can �:(� ' <br /> Installation Company Name and Contac!Inlo:.�i,;C.0 �i.U� l4�7`�)�294'��5� n'+'Y'�� a`�' '�'�)n `����'� ; <br /> Date Back��aater Prevenlion device(BlA'D)vras inslalled:��_�Date ihis form v:as compleled:.,�_ i <br /> Installalion Property Ov+ner Name and Coniacl Info:��{_t___i'j?���� - `J � �� _�� , <br /> Property Address: I ��� �A�P't"Q'Y i"P ��Ti� �� P/1 �"�T_'7 �n�C) � � <br /> Pre-Installation Inspection Checklist: � <br /> All items musl be checked'Ves'in order(or a BWD to be r.onsidered for installafion ' <br /> is there a basement or level of Ihe house that is at or near assumed sev�er main elevation7 [�"Yes ❑ No � <br /> Are Inere fixtures in the house located beloiv the uoslream sewer manhole rim eleaallon7�Yes ❑ No <br /> Is the side sewer currenlly UNPROTECTED frem seiver bac�ups (does nol nave a 8WD installed)1�Yes ❑ No ; <br /> Site Inspection Checklist: ' <br /> All r;ems musf be checked'Yes'be(ore inspectron is consrdered complete � <br /> /t_ i <br /> :�Jas side sewer TV inspected irom building io see�er main? �Yes ❑No Condilion' l� � <br /> Does side see�er have at least 1°o slope from ihc building to sevaer main? [�Yes ❑No Describe: f <br /> Have ail buildir,g sewer drain connections to ihe si�e sewer been identitied and localed? �Yes ❑No � <br /> Have all oroperty slorm drainage connections to C � side se�ver been identified and localed? �Yes ❑ �o � <br /> Hzs properly been evalua�ed for drainage deticiencies�:41h firdinys communicated to property ovrner? �j Yes ❑ No i <br /> Installation Details: r � � <br /> INhat type and brand of DWD e:as insfalled al this sile (Clean Check 9NN, Grinder pump, etc.):�G'tt'(��� n�"r r U � <br /> Where wa� the tlevice installed(general descriplion,attach map)? .�����,(,�',���-C'��S._!�L-f r rr ; <br /> ! <br /> Vt�2s there any olhei sevrer or sto«n drainage caork wmp!eted in conjunclion�vilh lhe 4WD v+oik? Is so please describe:_ � <br /> -------- — --- -- —i�.a��---- - � <br /> Installation Checklist: <br /> Arc all dovmspouts and site drainagr,disconnected from upstream of ihe Bl"D? �Yes ❑No CommeNs' i <br /> Does BWD posilioning meets minimum slope requiremenl oi>196? �1'es �] No Camrnents: , <br /> Can 8WD be pulted out for inspeetion and mainlenance after loosening ihumb scre�v? �Yes ❑No I <br /> I5 BWD locked into th�per-posilion and thumb screw tightened? �Yes ❑No � <br /> Circle Ihe BWD cov t: u� rigalion�over(lan scape area)!iraffic load bearing cover(drive suriace)I aceess hatch (building) i <br /> N�as property ovmr.r shown the loeafion of the installed BWD? jR�Yes ❑ No CommeNs: j <br /> � I <br /> .,i ,� ��� _�_ Date: � �S �� ' <br /> Property Ovmer's Signaluret ' - / � <br /> Insfaller's Signatuie: Date:�//_ -- � <br /> Revision:2 1 Friday,Septemher 11,7014 � <br />