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i <br /> �A�6�U�A`�ER PR�i/��Tl�f� ��1YI�E FINAL � <br /> � , <br /> si���'A�L�1'lC��9 CNE�K�IS� <br /> � <br /> � <br /> I <br /> Inslallation Company Name and Contact Info: Mo c.n r (t,,,�,�r;�n� ��L-U 3� �3 C.u � <br /> � <br /> i , � <br /> �ale BacMvater PrevenGon device(BWD)v,as instailed: 3 �—� S � aIe this form tvas compiried: '-�5- 1 S i <br /> Installation Property O�vner Name and Contact Inio: �Z��k �C.�+��^ �(� J ��(�f U�f 0�{ i <br /> Property Address: 1 y ( (. ��` �� I��.-e;--�,� ` <br /> � <br /> Pre•Instailation InspecUon Checklisl: <br /> All ilenu must be checked'Yes'in order fora BV✓D to be considered forinstallation <br /> Is there a basemert or level ot the house Ihat is at or near assumed sci�;er main elevation?�Yes ❑ No <br /> kre there fixtures in tne house locaied below the upstream se���er manhole rim elevation?�Yes ❑No , <br /> Is the side seti^er currentl��UNPROTECTED from sewer backups(does not have a BWD installed)?0 Yes ❑No ; <br /> Site Inspection Che�klist: <br /> AU Aems must 6e checked'Yes'6efore inspection is considered complete i <br /> NJas side sewer N inspecied from building to se��rer main7 �Yes ❑ No Condi�ion: �vc'�1 i <br /> Does side se�eer have at least 1%siope from the building to see�er main? �Yes ❑No Descrioe: ; <br /> Na��e all building se�vor dra�n conneclions to Uie side sevfer been identified and localed? �Yes ❑No <br /> Na��e all property storm drainage connecfions to lhe side sewer been identified and Iocated7 �Yes ❑�o i <br /> Has property been evaluated tor drainage deficiencies wilh findings wmmunicated to property o�ener? �Yes ❑ tJo ; <br /> i <br /> Installation Details: <br /> i <br /> INhaf type and brand oi BWD was installed al this site(Clean Check BINV,Grinder pump, elc.): � ��c;� LC.c c. �� , <br /> N�here�vas the device inslalled(general descnption,attach map)7 �--c�: ��-� t I <br /> t <br /> Was there any olher setver or stonn drainage work compieted in conjunclion wilh the �WD�vork7 is so please describe:_ j <br /> �1i/h I <br /> -� -- ------ <br /> Installation Checklist• <br /> Are all tlo�:�nspouls and site Arainage disconnected from upslream of ihe BVVD7 Ol'es ❑No Commonts:__ � <br /> Does�IND posltionfng meets minimum slope requiremenl of>t%? ❑Q Yes ❑�o Commenis: � <br /> Can BWD be pulled out for Inspection and maintenance after loosening ihumb screv,? �Yes ❑No ; <br /> Is BWD locked into lhe proper position and thumb screvi tightened? ,�'f Yes ❑�o ; <br /> Circle ihe BWD cover. irriq n�(landscape area)I(ra�c load bearing cover(drive surface)1 access hatch(building) i <br /> � 1'Jas property o��rner shown the locafion of the inslailed DWD? [�]Yes ❑ No Comments: __ � <br /> � <br /> � <br /> Property OwnePs Signature: �ate: _ � <br /> installers 5ignature: "� � /'Z��- Daie: � - �`' -r � ` <br /> Etevision:2 1 Monday,Septem6er 15,2014 ! <br /> � <br /> � <br />