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LZ <br />�,ae��vAr�:� �R�v�rv��c��u oevic� �in�A� <br />��s��a�.��,�riAr� ea�Ec�Lf�r <br />Inslailafion Company tJame and Conlacl Info: <br />Date eackwatar Prevention tlevice (BWD) wus ins�alled�_ � Daie ihis form was co��npieled:_____S Z(n r� S" <br />tnslalfalion Propedy Owner ��ame and Conlacl Info: ��� y wn wC- 1 3 0 2 y S-� <br />_.�--r----7--}----- -- <br />Praperty Address: _ 3 � - — <br />Pre•Inslallation Inspoction Checklist: <br />All ifoms musl be chacked '}'es'rn order /or e 8WD Iv be cpnsidered la installalion <br />Is Ihere z basemen! or Ievel ol Ihe house thal is at or near assumed sewer main elevalion? [K] Y?s ❑ No <br />l��e I�ere fixl��res in !he house lo�eted belo�v the upstrcam sew.er manhole rim e!eeation? �ZJ Yes ❑ h� <br />Is �he side seu•er currenlly UNPROTECTED frcro se�•rer 6ackups (does nr' have a BIWO installed)7 �J Yes ❑ No <br />;ile Irspectian Checklist: <br />AI! �tems must be checked 'Yes' be%re inspecfio� is ronside/ed Con)plefe <br />l`ias side sov,�r TV inspecled fcom building to setver mainl �] 1'es ❑ No Conddlon: <br />Dees side sewer have ol least 1°/, siope (rom the building to sewer main7 (�c Yes ❑ Wo Descrit�: <br />flava ail building sewer drain connoclio�is lo lhe sitle ,e�ver �en identified and Iocaled? j,,� Yes ❑ No <br />Have all property slorm diainage connectlons Io Ihe side se�var been idenhfied and localed7 �] Yes �� rao <br />Has property been evaluated for draipage deficlencJzs wifh (indings communicated to prooerty ewnei? � Yes � ��'o <br />Installalion Details: <br />Vdhat type and hrand of BWD was insta{led at Ihls sile (Clean Check BNN, Grintlor pump, elcJ: � ��Q,�n �h�L <br />VYhere ���as the device Installnd (gennral descripllon, al(ach map)7 OU��__�j,{}��� <br />1'Jas Ihero any olher sewer or storm dreinage woik compleled in conjunclion v,lth Ihe BWO wnrk'l Is so pluase deScriDe� <br />InstaUation Checklist; <br />Aie all downspouls ond,ile drainage disconnecl�d from upslream ol iha f]�ND7 �;] Ye;: ❑ No Commenls: <br />Does �14�D pasicicning meels minimum slopc req�;immenl of >1°l09 [� Yes ❑ pJo C,�mmenls: <br />Can BWb be pul!ed oul lor Inspecllon and maintenance after loosening lhumb screwl �'� Yes � n�o <br />Is BWD lockod inlo lhe proper pos/ilipn.andthuu� screw liyhlened7 � Yes �] No <br />Circle Iho (3VVD cover. irrigalion cF`r`�`r (I`ndscape aro���aNic load bea�ing cover (dri��o sudoce) ! access halch (bullding) <br />Was {:�operty o�vner sliown lhe lor,alion o�fie msfalled BV�'U7 � Yes ❑ No Commenls: <br />�Nroperty Oaner's Sfgnelure: ���1/ r/ � -- <br />Dale: <br />Ins�allor's SlgnaW .���G� L��— — L'. i Dalo: _ <br />--"_-� <br />Rrvision� 7 1 Friday, �epiember 12, 201a <br />