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�A�KWATER PREVENTION DEVICE FIfVAL <br /> �, INS�ALLATIC1iIV GiiEC�(LIST <br /> ^'� 5"d� SC' �� L LG <br /> �'1'}���-�Cccl� `.x',�tl C , � -�' � <br /> . [ _' ( lf 5�'_�'��'rL ��'�i,l'�/�r� .�7CLS`�� <br /> Icst211alion Cn npany Namc antl Centact Inlo:�,CC ' (,[,�J�)_,}44- I _..J� <br /> Date E3acln•,ater Frevention deviee (BNJD)+�:�as insta'Jed: 1��.jZ__Date Ihis torm vras completed: � �� s _ <br /> Installalion Property O�vner��ame and Contact Inio: �r�'Y�_�[.��Is�`1��—a,�-�--��"-7�-- <br /> ' l A, � . .���.+t�-�����1 -- <br /> Property Address:�L�'�S�.YJL--�--- <br /> Pre-Installation Inspection Checklist: <br /> Al!items musf be checked'Yes'm o�der for a BbVD fo be r.nnsidered for inslalia'icn <br /> Is there a basement or level oi the house Ihat is at or near assumed sev�er ma�r elevation? r�(Yes [���i�, <br /> A;e there fixtures in thc house located beio�v Ihe upstream se�ver manhole rim eleva?,on?[�Yes ❑ '�•o <br /> is ihe side se�:er currentl;�UNPROTECTcD irom sewer hackups(dees not nave a BtVU instal!ed)?�j Ye> ._] lo <br /> Site Inspection Checklist: <br /> Ah uems musf be�hecked'Yes'before inspecticn is considered ccmp'eie �,� I <br /> !,1'as side sc�ser P.�inspected fro�n building to se�.ver main� (�Yas ❑ IJo Cor,dition ��-7C�[ri _— _--- <br /> Joes side see+er have at least �°o slope from the huild�.ng to searer main7 [�.Yes ❑ No Descrl�e: <br /> Have all buiiding seerer drain connect�ons to ihe side sewer been idenUfied and Iocatedl [�yes ❑Ido <br /> Ha��e all propert,slorm dr2incge connecfions lo tt�.e side se�•,er 6e�n idzntiEed and located? [�Yes ❑ D!o <br /> H2s preparty been evaluated tor drainage deticiencies�v�th findings communicated lo prepety oemer7 �Ye- [1 �!� <br /> Installation Details: <br /> `iJhat type and brand of B`ND�vas inslalled at this site(Clean Checic 91NV, Grinder pump,etc.) _����� � ' <br /> 'i��heir,�vas ihe device instailed(general description,attach map)��f��'.�C3��1�`�__e�__J���— �=��� <br /> !;�as there any olher sewer or srorm drainage���ork comp!e_ igd in conjunction�vitn ihe BIND e;otk? Is so Flease desc�ibe:_ <br /> �5Y_l�C__ <br /> Instailation Checklist: <br /> N�e ali dovmspouls and sfte drainagr,disconnecled from upstream o(the DUJD? �Yes ❑Plo Comments .__ _, <br /> Does BWD positioning meets minimum slope requirement ot>1407 �Yes [� No Commenl5 __ __ <br /> Can B�VD he pulled out for inspe�tion and mainlenance afler laosenir.r,thumi�scre�v� �Yes ��W:; <br /> Is BIND Incked inro lhe proper osition and lhumb screv�tightened? �Yes ❑No <br /> � Circle the BWD cov .irrigalion cover paridscape area)1 tralfic loatl bearing r.over(drive sudace)/acc;�ss halcii (bui�d�n_r,) <br /> i l�Vas propert/owner shoti+m"I�location of Ihe insialled B4UD? [�Yes ❑No Cornmenls: <br /> � Property Owner's Signaturg�,fi���� __ Date: / �G j- <br /> ; � . �. Date: � ��I�,S-- <br /> Installer's Signaturc:______���/`'� <br /> I Rocisinn� i 1 frlday,Sop.cmber 12, ;Oi4 <br /> - - — <br /> �I---- _. ------- ----- -- ---- --�---- <br /> � - �--- �- -- --- -�-- <br />