2311 STATE ST 2016-01-01 MF Import

�e��g�4A��6� ��19��°9�6� ��l0@�� F@NA� rr @R9�`��9afl��°�9�+(�! ��-6��EPP�B�`�' �._�_,�._ — InslallationCompanyNameandContacllnfo: l�''�D�l� ��,�,�;•�� `�'a� �C,U �360 Date Back�vater Prevenlion device (BWD) was installed: U Date ihis form vdas completed: S-� o— r f installafion Property ONmer Name antl Contact Inio: _«t�f,.�l U� r �l l� ik �� Property Address: a 311 �cr}-e Sd • Pre-Installation lnspection Checkliaf; All items must be checked'Yes' in order for a �314�D l0 6 considered forinstalletion Is lhere a basement or level oi lhe house lhat is at or near assumed sev;er main elevalion? �Yes ❑ No Are tliere fixlures in ihe house located belov� the upstream se��,�ar manhole rim elevaiion?��Yes � No Is the side sea�er currenUy U�dPRO7ECTED from sewer bacicups (does not have a BWD insielled)T �Yes ❑ No Site Inspection Checklist: All ifems musf 6e checked'Yes' beiore inspectlon !s consrdered r,omplete bVas side sewer N inspecled irom building to sewer main? � Yes ❑ No Condilion: �� Cr1�c1 Z Does side se�ti�er have af least 1 io slope from ihe building to sewer main9 ❑ Yes ❑ No Describe: _ Have all building selver drain connections to the side se�ver beon identified and located? ❑ Yes ❑ No Have all property storm drainage conneciions !o the side setver been idenfified and locatedl ❑ Yes ❑ No Has property been evaluated for drainage deficiencies voith findings communiceled to properly owner? ❑ Yes ❑ No InsWllation Defalis: \��hat fype and brand of DW� was inslalled at this sile (Clean Check BWV, Griader pump, etc.)' VJhem was ihe devir.e installed (general descriptlon, alfach map)? Was Ihero any other sewer or storm drainage �vork compleletl in oonjunclion wdh ihe BWD work? Is so please describa: , Inslallation Checldlst: Are all downspouls and siie drainaye disconnecicd from upslream of lhe BWD? ❑ Ycs ❑ No Comments: Dn�s 8WD posltinning meets minimum slope requirement of >7'/0? ❑ Yes ❑ No Commenfs: Cen BWD be pulled oul for (nspection ond maintenanco after loosening Ihumb screw? ❑ Yes ❑ �o Is HWO locked into the �roper positlon and ihumb screw tighfened? ❑ Yes ❑ No Circic the BWU cover. irric�ation r.over (landscape area)1 traffic load bearing cover (drive surface)! access halch (ouilding) Was property owner shown Ihe localion of tha inslatletl BWfJ7 ❑ Yes ❑ No Commenis� Property Owner's Signature: Instaliers Signafure: Date: Date: � Z � � �� Revision: 2 1 Monday, Septemher 15, 2014