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��,CE(V16ATER �R�i/Ef�T�ON DEVICE FINAL i <br /> 9f��TAL�.ATI�N CNECK�iSl' i <br /> � <br /> i <br /> Installation Company Nameand Contad Info: M ���"' I���rr�����t y i-( � � - �(,U-b'3�c { <br /> � � <br /> Date BacMvater Prevention device(BWD)was inslalled: �-�� �� Date ihis form�vas completed� u-�6'--�� � <br /> Installation Properiy Oerner Name and Contact Info: ��Y'�+� L'4��S� � <br /> � <br /> PropeRyAddress: �� c a L'���Z /w�- ' <br /> Pre•Installation Inspection Checklist: � <br /> All items must be checked 'Yes'in order/or a BIND to be consfdered for installation � <br /> Is there a 6asement or tevel of ihe house that Is at or near assumed se�ver main elevation?�Yes ❑No � <br /> Are there tixtures in the house located below!he upstream sewer manhole rim elevafion?�Yes ❑ No ; <br /> Is the side sewer currently UtdPROTECTED trom seH�er backups (does noi have a BWD inslailed)?BYes ❑No � <br /> Slte Inspection Checklist: � <br /> All items must be checked'Yes'belore inspection is considered complele ; <br /> 1�'as side sza�er N inspected from building to sewer main? �Yes ❑No Condition:�rUl�-Q+'� i <br /> Does side se�ver have at least 1%slope from the buildi�g to sevrer main? �Yes ❑No Describe: � <br /> Ha��e all building sewer drain connections io the side sewer been identified and located? �Yes ❑ No { <br /> f <br /> Have all property storm drainage connections to the sidz sewer been identified and locatetl? [�J Yes ❑ No <br /> Has propedy been evaluated(or drainage denciencies a�ith findings communicaletl lo property owne�7 Q Yes ❑tVo ; <br /> Installation Details: ! <br /> What lype and brand of BWD was installed ai this site(Clean Check BVJ1�, Grinder pump,etc.): L�•-���r ,-c�-«< �L-� ; <br /> 4Vhere was tho device installed (general description, atiach map)? 13�-i�r--+����' h� S�-�c ' <br /> 1Nas there any other sev�er or storm drainage��;ork completed in conjunction�vith the BWD Svork? Is so please tlescribe:_ ; <br /> �� � <br /> Installation Checklist: i <br /> Are all do�vnspouls and site dreinage tlisconnecled from upsUeam oi the BWD? �1'es ❑No Comments: •. <br /> i <br /> Ooes BWD positioning meets minimum slope requirement of>1%7 ��Yes ❑ No Comments:_ � <br /> Can BN�D be pulled out for inspection and maintenance efter loosening thumb screw? ❑Yes ❑No ` <br /> i <br /> is BlNO locked inlo the proper position and Ihumb screw tightened? ❑Yes ❑No � <br /> Circle the BWD cover: irrigation cover(landscape area)1 iraHic load bearing cover(drive suriace)1 access hatch (building) ! <br /> Was property o�vner shown the location oi the inslalled 8WD? �Yes ❑ Ido Comments:_ i <br /> Praperty Owner's Signature: Date: I <br /> Installer's Signature: <br /> � ,�/�`z-�-- Date: � 'a�'� � ! <br /> � <br /> Revisfon:2 1 Monday,September 15, 2014 j <br /> � <br />