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�A�E�l�1'�f� PR�V��9i��� D�V�C� ��i�A� <br />8�9�`�A�.�.6�`�EO�R �1-I��K�IST <br />Installalion Company Name and Conla�t Info: M lY� I/ ��,n f� � <br />S — %�.U-�i'ZGu <br />v ?—!S -I)" <br />Dafe Bac6��+ater PrevenGon devica (BWD) v,�as inslalled: �-�� - r� Date this (orm edas completed: <br />Inslallafion Properfy O���ner 1Jame and Contact Inio: � f.n �O � �'�- � (�� �, i S _ <br />Property Hddress: �`'� �� �2� � l�v� t% �--�_, c, a"� <br />Pre•Installation inspection Checklist: <br />All items must be checked 'Yes' in order for a BLND lo bs considered for instaflation <br />is there a basement or level of lhe house Ihal is at or near assumed ss�s�er m2in elevation? (�Yes ❑ t�o <br />Ara Ihere iixtures in ihe house located belo�v the upsVeam se�;�er manhole rim el�vahon7 (Sj Yes ❑ No <br />Is the side sevrer currentty UNPP,OTECTED from se���er backups (does not have .� 8'�ND insialled)? � Yes ❑ No <br />Site Inspection Checklist: <br />All dems must 6e checked `Yes' belore inspection is considered cornplete <br />�Vas side sevrer N inspecied from building to seraer main? �Yes ❑ No Condilion: �/`�-� <br />Does side se«�er have at lea:t 1% slope from the building to sevrer main? 0 Yes ❑ No DescribE: � <br />Have all building sesver drain comiecfions to the side sewer been idenGfied and localed? � Yes ❑ No <br />Hat�e all prope�}� sform drainage connections to lhe sitle se�v2r been identined and locatedl �Yes ❑ No <br />Has property been evaluated for drainage deficiencies v,iih findings communicated to property owner7 ��Yes ❑ No <br />Insfalla:ion Details: <br />What type and brand of BWD �ti�as installed at this site (Clean Check BWV, Grinder pump, ete.): C�'c, .<- G..�- c.�c <br />V�'here �:�as the device inslalletl (general descriptfon, atlach map)? I�r c• �� •�c..� ' !�� � S4 �� _�, <br />• i <br />Was ihere any other sewer o storm drainage vrork comple�ed in conjunction ��,ith the BWD ��:orie7 Is so piease describe: _ <br />/�� fk — <br />Installation Checkiist: <br />(+re all dov+nspouls and site drainage disconnected irom upsiream of the BIND? ��Yes ❑ No Comments: <br />Doss BWD posilioning meets minimum slope requiremenl of >1%? �]Yes ❑ No Comments: <br />Can BVdD be pulled out for Inspection and mainlenance after loosening thumb screw? N Yes ❑ No <br />Is BI��D locked into ihe /propEr_position and thumb scre�v tightened? ��J Yes LI No <br />Cir�le the BWD cover.V�ngatlon cov�(landscape area)1 tra�c load bearing cover (drive surface)1 access hatch (building) <br />Was property o�vner shown Ihe location of the installed BWD? (� Yes ❑ No Comments: <br />Prope�y Oa�ners Signalure: Dale: <br />inslallers Signature: ����, ��� /�Z� - Date: �7 � �S � �� <br />Revision: 2 1 Monday, September 15, 2014 <br />