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V <br /> i <br /> I <br /> �A���/����� �������e�� ������ �5��� <br /> i <br /> �/ Eltl� i 9'+L.6.P'+ 1 I�Itl �o���f�A���� <br /> I <br /> ���r� c�:�n �x�(� � � �r ����de eaz ��z�- �. �c � <br /> Inslallation Company Name and Contact Info.��CC • -� (1( �)•�jlj -C�S�i��'ik�� ��`+G)r��In �/jS� � <br /> Date Backc�ater Prevention device(BWD}ti��as installed:�?f i��1 i s Date this(orm was completed: � �" i <br /> i <br /> Installation Property Ov+ner Name and Contact Info:_���,�n_��.tr��_�t� " u7� " ���� ' <br /> Properfy Address:.ca.Q:�--�-.�, ., j.L�.��—;�'��(---=-r— �- i )t';L{���•� �� � <br /> � <br /> Pre•Instailation Irspection Checklist: ; <br /> Afl ilems musf be checked'Yes'in order for a BIND to be considered(cr installation � <br /> Is the�e a basement or(evel oi the house thal is at or near assumed se���er main elevalion?� Yes ❑ No <br /> ,+re there fixlures in the house foeated beluw the upstream set,�er manhole nm elevation? �J Yes ❑ No i <br /> Is tne sitle se:ver currently UNPROTECTED from see�er backups (does not have a BWD installed�?�Yes ❑No i <br /> 5ite Inspection Checklist: <br /> Hil items musl be checked'Yes'beiore inspection is cons�dered complete ! <br /> 'ii�as side se�ver N inspected (rom building lo see:er main? �]Yes ❑ No Condition:__L�7._���� f <br /> U�es side sewer have at least 1% slope from Ihe building to sev.�er main7 (�Yes ❑ No Describe: � <br /> Have ail building se���er drain connections to the side see;er been identi��ed and located? �Yes ❑ No , <br /> Have all propeny stortn drainage conneclions to the side sewer been identified and located? [�Yes ❑ No ' <br /> Has oroperty been evalualed ior drainage deficioncies with 6ndiugs communi�atad lo property owner? �'Yes ❑No ; <br /> Installation Details: n ? <br /> What type and brand of BWD eias installed at ihis slte(Clean Check BWV, Grinder pump,etc.):�f'C Cl�, '/� v' f � ; <br /> ln,q,ere was the device instal;ed (general description,attacli map)? �£'P ��'� ��k��S_��L.C.e� <br /> i <br /> ----- � <br /> V�'as there any other sev+er or sform drainage u�ork complet d in cronjunction�vith the f31ND v+ork? Is so please tlescnbe:_ j <br /> -- --- ----- ------ ----�Cj'��- --- i <br /> Installation Checklist: <br /> Are al!downspnuls and site drainage disconnected irom upstream of ihe BWD7 � Yes ❑vo Commenls: i <br /> Does BWD positioning mects minimurn slope requirement of>t%? �Yes �_� ho Commenls: _____ <br /> Can 8WD�e pulled out(or inspeclion antl maintenance a(ter loosening thumb screw? �Yes ❑No i <br /> Is BWD lor.ked inlo lhe pro�er positlon and ihumb scre�v tightened? �Yes ❑No ' <br /> � 1 <br /> Gircle the BWD covel�riyalion cove��ndscape area)i iraffic load bearing cover(drive suriace)I access hatr.h (�uiltlmg) <br /> Ut�as property owner shown ihe localicn of the inslalled BWD7 �Nes ❑ No Commenis: � <br /> ,, _ (l', / l i <br /> c�ropertvOwner's5ignaWre: L��:-`l/o `t����f�--�.- Dale: �� /� '•�-�J ' <br /> Inslaller's Signalure:__ � Date:� � �1� ! <br /> Revision: ? � 1 Friday, Seplernbr.r 1.2, 207d �� <br /> i <br />