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� ������`���'k�� �E���.��G�`j'@�� ���',r�� �a��9�,�, <br /> b�"`� <br /> �=�� ���i�`�'�a .8������>9 �6—���?��9��' <br /> •--._..1.�:.�,.t�-�-�m�>...-_.r.-'"'.�'..��._--�.�_=v�--.._t�a.,«z��r�....._=��r. - . <br /> ins�auaE�on Company Name and Contact Inio: IhUe� �� � -� ` � ` <br /> ��,h:.�y ���.76U��C�c� <br /> Uale Backvrater Froveniion dei�ice(BNrp)v�as ins(a9ed: �o -��Dafe tnis iorm v,�as comp!e,ed: �u-��-�f <br /> Instailation Prcperty Owner ldame and Coniact Info: r�a�,�,,,,, � ��""" <br /> /?� c �- <br /> Property Address:�! �� f r ----�--.� <br /> P;,;•Ins4allati�n InspeCuon Checfclisi: ------- <br /> .7l1 irems must be checkeu'Yes'in oroer ior a 8WD to be considered forrnstallation <br /> is iher2 a basemeni or level ef the housa fhat is at or rear assumed serrer main elevation7[�Yes ❑ p!o <br /> Are (here fixfures in the ho��se iocaied belotie the upsfream se�,var manhole rim elevarion?[�Yes ❑ Plo <br /> Is'.he side set;er cur;ently UN?ROTEGiED irom ssere;backups(does nof have a BI�VD insialled)?�Yes ❑ Dlo <br /> Sifa Inspecuon Checklisi: <br /> Ai,'rtarr;s musf be checked`Yes'beiore ir,specfion rs considered comp/e;e <br /> d�;side sev;er N irspecied from building io seede�main? �sj 1'es ❑(�o Conditicn:S�4 �,n 1 <br /> Do�;;ide sewer have ai lesst 1%slope 7om�he 6uilding io serrer na�n? �]Yes ❑ (do Des�rbe: <br /> -;a;�e all builtling sev:er drain conneciicns to fne side se;ver been i�en5ned ar�d located? �yes ���o <br /> H�ve all prop2ry starm drainaye conneciions io the side se�•1er Ceen iden6fied and Iccai2d7 (�Yes ❑ No <br /> Has proper�j be�n evaluaied io;dreinage de��ciencies t�:�iih fi idinas communicated to prop:rt;oemor? @�Yes []t�lo <br /> Insf�ffaricn Ueiaii,; <br /> 1Nhzt type end trand of BWD ti:as insta(led at this siie(Clean Check BV�l1�, Grinder pump, etc.)� C.a„ p/c r d���^-'� <br /> 14,1hEfB N18S the device inst�lled(generaf descripiior.,atiach map)? f3u it �- �— �4� <br /> bvas there any oiher sawer or siorm drainage wodc compieted in wnjuncuon�vith ihe BWD v�ork? is sr please describe: � <br /> - _ /1///k _ <br /> Installafior, Checi;lisf: t � -- --'- �----•�— <br /> Arr all downspouts and siie drainage disconnecfed irom upetn;am of lhe BIND? Yes <br /> I� ❑No Comments: <br /> Daes B!��!� pnsicioning meets r��i,�ir�am slape requiremeni of>i°o? Q�Yes ❑iJ� L'ommenis� <br /> Ca+i BWD be puiletl oul for inspec�ion and nain�enance after loosening thm�h ssrev�? f�f1'es ❑�o ' <br /> Is PVUD locked into the proper position and ihumb scre�v tightaned? �Yes ❑�o <br /> C' r.�e the B!�'D cover:irnga(ion co��er(lantlsrapa arFa;!tra�c lo�d bearing cover(dm�e surace)1 zccess h�ich(building) <br /> ':':'as proper��n!vner shov!n the locafion of the installed BUJD'? �Yes ��o �ommenl;: � <br /> P,operbj Ownei's Signaturo: Date: <br /> Installer's 5ignafure:_�-�''7��� � � D�(e; �J -`�-IS� <br /> ----_�..—._...,__._._��� <br /> RevLlon: 1 1 N�onday,Septem6er 15,2014 <br />