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��4C�VilAT�R l�R�VEIVT60N D�VPGE FIIVAL <br />SNST�►�Ld�iI�N �HEC{4L15T <br />I.�stallation Company Nam2 ar:d Coniact Inio: `;,-� <br />D2;e Backwaler Prevention device (41�'D) was insialietl: <br />Installaiion Propery Osrner Name and Con�ac( Info: <br />Pro;?ertyP.ddress: ��'Q� ��`1'Vl <br />Dafe Ihi; iorm s�as compteled:` <br />Pre-Instailation Inspection Checklist: � <br />All ilems must be check2d Yes' in ord�r l�� � d�/i'p ;�� �2 � �r,sidered ror ir,starraG�,� <br />I; tnere a oasE,�l�ftl Or IaV210( ihB ii�p;15B. ihA' IS 81 0� n�8� "dSSUm@�j eav�p� �t?in e!�vet.inn^ I� ac I—1 �J� <br />Y.... <br />kre therF fixiures in ihe hcuse !ocated hetuv� Ihe upstr<arn sev�er manl.o�e run =1eva!ion? `�i Yes ❑ Mo <br />Is !hc side se:•;er currenl;y UIJFP.OTEC:TED irom ses;�ar backups (ooes nof have a BWD instaliedj? � Yes � No <br />Site Inspection Checklist: <br />.41I ilems musr bQ checked 'Yes' helore inspect�on is consiUered complefe <br />Vdas side seever TV inspect2d trom building io ;ev.�er rnain? jY� Yo; ❑ No Condition: <br />Does side sewer ha��e ai least t% slepe from ihe building to sev;er main? �] 1'es ❑ No Describe: <br />Hzve all building sewer dr2in conneciions to the side sev�ar been iden;iiied and lecated %� Yes ❑ No <br />Have ail properfy storm drainage connectior.s lo ihe side se�,:er be2n id2niified and loczted? I� Yes ❑ No <br />Has prooerty been evalualetl for drainage defcian�ies witi� (indings communicat2d to proper'ty oransr� � 1'es ❑ Mo <br />Instaliation Details: <br />Wnat type and brand of 8WD vras ins�a!led at ihis site �Ciean Check 84^/U; Grinder pump. etc.). _ GI F�,,n GhPf. � <br />�PJh�re was the device inslalLd (yeneral descripfion, a!izch ma�)? �U._ 1 1��_�-�, <br />Was Iher2 any other seover or storm drainage vrork ��ompt�ied m conjunction �v+th fhe BWD vror'r,? Is so please describa: <br />Installation Checklist: <br />A;e all dov,�nspouts and site drainaoe ciisconneGed trom ��pstrea;n o( tiie BWD- � Yes ❑ No Comrnsnis: <br />Does BWD �ositioning meets minimum sfope requiremen� oi >1?4,? �?,1'es C� p!n Cam�enis: <br />Can BWD be pui�ed oul to; inspecfion and maint�nance aNer loosenino Ihumh screat? � Yes ❑ No <br />Is 6lND locked into Ihe proper positi�,r�1W�m_ ;crev, iiohlened? <br />fL,,` � L�1 Yes ❑ rdo <br />Cucle (he B�NO c�vyr. irrigalion c�er Qsndsr�pe area)� ratfic load bearing mver (dri� e sudace) / �CCr>c ficff,Il �buildin�) <br />Was p!openy ovm�r;hown ihe localion oi (fieinst IIeG p�/Jp? �1 Yes Q No Cummenfs: <br />�`ProFer� j Otvner's Sionature: '— � <br />—�1.—� �-` �t'`"`� Oale: —�1��.=2C�1� <br />!^ .;-- ._ � -- <br />Insl211er's SignaWre:�2%y C ,j- '/L . {! .�� . <br />--� =—�---L_� _ _ �ate: <br />Rc��ision: 2 1 friday, Septembr.r ] 2, 201n <br />