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����r���� ���v��ti i�� ��vic� �i�a� <br />� � 6i��i�Li.A�'I��! �l�EClKL15T <br />(nsta�lation Company Name and Contact Info: I i�,t �1 ����,,��9,vy ��ZS '%G u,� 1C. U <br />Date Back�vater PrevenGon device (BIND) was Inslalied: ,-.Z G- f SJ �Oate ihis fortn vaas compteted: 7�� y^� f� <br />Installation Properfy Owner Name and Contact Inio: S D' �Y IIU�i � �� �-(,� S�— � S S— 15 ytl <br />� ' <br />Property Address: __ 5 5.� S� r d I�y 1- r- c �-t' f� <br />Pre•Installation Inspection Cliecklisl: <br />Afl ilems must be cliecked'Yes' in order lor a BWD to be considered for instellstion <br />Is there a basemenl or le��el of N�e house lhat is al or near assumed sevrer main elevation? Q Yes ❑ �o <br />Are fhere flxtures in the house locafed belov+ the upstream sewer manhole rim elevation? [3�] Yes ❑ No <br />Is lhe sitle sewer currently UNPROTECTED (rom seveer backups (does not have a BIND installed)? � Yes ❑ i�o <br />Site Inspection Checklisf: <br />All items must be cAecked 'Yes' before inspec(ion is considered complefe <br />Was side sewer i V inspected irom buifding to sevaer main7 � Yes ❑ No Condition: /le�J <br />Does side setvor have at least 1% slope from the building to sewer mainl � Yes ❑ No Describe: <br />Have all buiiding sevrer drai� conne�tions to the side sewer been identified and localed? �Yes ❑ No <br />Ha¢e all property storm drainage conneclions to lhe side sewer been identifi�,', and located? �' Yes ❑ No <br />Has property been evalualetl for drainage deficiencies wilh findings comrrunicated lo property owner? � Yes ❑ No <br />tnsfallation Details: <br />lti�hat lype and brand of �WD �+�as inslalled at this site (Cleasi Check BWV, Grinder pump, etc.): �,� f�c,. cL.<• c!� <br />VJhere was the device inslalled (general descriplion, attach map)? �,_, y� i'? <br />Was there any other sewet or stonn drainage work completed in conjunclion �aiUi the BWO v�ork7 is so piease describe� _ <br />/L� �a <br />Insiallation Checklist: <br />Flre all downspouts and site drainage disconnecled from upstream of the 6WD? Q�Yes ❑ No Comments: <br />Does BWD position(ng meets minimum slope requirement of >1%? � Yes ❑ No Comments: <br />Can DVVD be pulletl out for inspeclion and maintenance after loosening lhumb scre�v? B Yes ❑ No <br />Is BWD locked info lhe proper posilion and thumb screw lighlened? �j�Yes ❑ No <br />�----- �. <br />Circie lhe B�ND cove�r�irngat�oR cove �(landscape area)1 traKc load hearing cover (drive surtace) ! access hatch (building) <br />Nlas property owner shown the location oi the installed BWD? � Yes ❑ No CommeNs: <br />Properly O�vner's Signature: Date: <br />Installer's Signature: �--�1 ,! %a � - Date: 3�( S� r S <br />Revisfnn: 2 1 Monday, September 15, 2014 <br />