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i <br /> I <br /> i <br /> �o-��v����� ���������� ���I�� �'O�d��.. i <br /> E������..������ ����{'t�.,��T � <br /> , <br /> d� f <br /> � <br /> Installation Company Name and CoMact Inio:_M ��� I��H�����»y �-/ � 1=- ]�U �d 3�c � <br /> Date Backt��aler Prevenfion devi�e (B1N�)�vas installe�: `�—L — + I Date fhis form was completed: �� -C� - !� � <br /> Installafion Property Owner IJame and Contact Info: S�'e-�~� � ,� ; <br /> Property Address: � � �� �� � ,�lu-� � <br /> � <br /> Pre•Installation Inspection Checklist; ' <br /> All i�ems r»ust be checked'Yes'in order for a BIND to be consldered lor instailation ; <br /> Is there a basemeni or level of the house ihat is at or near assumed sewer main elevation?[�Yes ❑No j <br /> Are there fix�ures in the house located below the uostream sewer manhole rim elevation?�]Yes ❑ No � <br /> is the side se���er currently UNPROTECTED from sev�er bac'tups(does not have a BWD installed)?�Yes ❑tdo ! <br /> � <br /> Site Inspection Checklist: i <br /> AIf iiems must 6e checked'Yes'before inspection is consider�d complete � <br /> lh'as side se�ver N inspected from building to sewer maln? �Yes ❑ �o Condilion: d fQ S ru,�� � C�,�,L '; <br /> Does side sewer hava at ieast 1%slope irom the building to selver main? �Yes ❑ No Describe: <br /> Have all buitding seiver drain connecfions io the side se���er been identified and located? [�j Yes ❑ No � <br /> Hava all property storm drainage conneclions fo the side sewer been identii�ed and located? Q Yes ❑ No i <br /> Has property been evaluated for drainage deficiencies�vith findings communicaled to prope�ly owner7 (�(Yes ❑ No <br /> l <br /> Installation Details: j <br /> V��haf type and brand of 84VD�t�as installed at this site(Clean Check BWV, Grinder pump,eic.)' �4�,�ec,�. c 4a�K ! <br /> lNhere tvas lhe devlce instalted(generzl description, atiach map)7 S u��"�+ s��Lc vS h.�,� � j <br /> ����� � <br /> i <br /> Was there any olher sewer or stnrm d�ag�ivork completed in conjunction�vith the BWD tvork? IS so please describe:_ � <br /> r j ' <br /> � <br /> Installation Checklist: <br /> Are ell do�vnspouls and site drainage disconnected from upstream of the BWD'? �Yes ❑ No Comments: i <br /> Does 8t1�D positioning meels minimum siope requireme�t of>1°6? �Yes ❑��o Comments: <br /> Can 814�D he pulled out for inspection and maintenance after loosening ihumb screw? �Yes ❑ �o i <br /> Is BWD locketl into the proper posilion and thumb scre���lightened? �(Yes ❑ No � <br /> Circle ihE BWD cover ritL Bg Gon co�(landscape area)I traffic load beaiing cover(drive surface)!access hatch(building) i <br /> VJas property owner shovm the(ocation of the instailed BWD? �]Yes ❑No Commenis:_ � <br /> . � <br /> 1 <br /> Property Ovmer's Signature: Date: 4 <br /> Instafler's Signalure: ���^ ��-- Date: �/- 6 --I.S� j <br /> f <br /> Revlsion: 2 1 Monday,Septem6cr 15,2014 ! <br /> � <br />