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I <br /> � <br /> }� ����Ff�'�1"�� �����P�T&�i� ���l6�� 6�iE��.l. ; <br /> ��,� E�I��A�.���6�� �Ei��KR_f�T � <br /> ; <br /> ; <br /> ;nsfat'ation Cempany Name and Conlact Info:��� ���.N+�,�-�J �l�-S� 7� Q �� C o i <br /> a � <br /> Da:e Bac6�,�ater Prevention device(BI�VD)v:as inslalled: 2' �2' �5 02te lhis form�vas comp�eted: 2� ��— l� � <br /> Ins".aliation Property O�aner Name znd Contact In(o: �u e_ i^^� � � �c-� _ � <br /> Prc;perty Address: �_�,� �02 f-k � f't,� (:�-cr-c-�' l./� �7�7—v I � <br /> i <br /> Pre-installation Inspection Checklist: � <br /> i <br /> Afl iterns must be checked'Yes'in wder for a 84VD to 6e consrderedlor inslalletion ; <br /> Is there a basement or ievel ol the house that is at or near assumed setver mc�n elevation?�Yes ❑ �o j <br /> �,re tnere tixtures in the house located he;o:v fhe upstream se+aer manhole rim elevation?�Yes ❑ No ; <br /> Is the side se�ver currently UNPROTECTED from szti•:er backuas(c�es not have a BVJD insi�lled)? �Yes ❑ Nn � <br /> Site Inspection Cheeklist: ! <br /> i <br /> A4 itents must he checkad'Yes'be;cre inspectron is considered complefa ! <br /> U:�as side see;er N inspacted from 6uilding to seerar main". (�Yes ❑ No Condition: �°t'���`c-d-� � <br /> Dces sidc sevrer have at least i% s�opz from the building to se�ver mai�9 �C]Yes ❑ No Describe: ' <br /> I{ave ail building ser�er drain connections to Ihe side ser:ar been idenlif�ed and tocated? X�Yes ❑ ho I <br /> Ha��e all property storm drainage conneclions to the side se�ver been idenlified and located7 [�X'Yes ❑10 � <br /> Has property been evafualed tor drainage deficiencies:+ith findings ccTT�uni�ated lo propeny owner? � Yes ❑ Ido I <br /> Installafion Details: � <br /> l'dhat type and�rand of BWD v:as instailed al this site(Clean Check BVJV, Grinder pump, etc.)• G(e•;n c (..�k _ ; <br /> 'i:'here tras lhe device instal!ed(general description, attach map)? �� s; ��- �� •��^�-�_ � <br /> � <br /> ll'as lhere any other sel:ar or storm drainage svork c:ompleted i� conjunction wdh ihe BPdD wor�? Is so pleaee describa: ._ ; <br /> ��g ' <br /> Installation Checkllst: i <br /> Are all do���nspouts and site drainage disconnectetl�rom upstream o(lhe BIND? �Yes ❑ Ao Commenis: __. ! <br /> Does BWD positioning meels minimum slope requiremenl of>t%? �Zj Yes ❑ No Commenis: _ � <br /> Can BVJA be pulled oul tor inspection and maintenan�e after loosening fhumb scree;? �Yes ❑ No ! <br /> Is 8Ut'D locked:�lo the proper position and Ihumb scre�v tightened? �Yes ❑ No � <br /> Circle the Bt�UD coo�r. i i ation cove 'andscape area}!tratfic load bearing cover(drive sur(ace)!access hatch(building) ; <br /> VJas property otivner shown the Iocetion of Ihe installed BWD? �Yes ❑ No Comments: � <br /> Property O���ner's Signature: Dale: ' <br /> i <br /> Installer's Signature: �%L-•----� Date: a — �7` � s ! <br /> Revision� 2 1 Monday,September 15, 201�1 1 <br /> f <br />