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a <br /> �R��e1i1fA1"ER i�REVE�ilTI�� �El�ICE �lf��� � <br /> d <br /> �f�STA(��A�'BG�f� �HECi��I��' � <br /> i <br /> 1�'lE-ri cczr� �.-x�p�-� � � ,�,d< <,c..L�-, �. �.� <br /> Insfallatron Company Plame ard Contact In`o:.>>Ci i L:[,�f ��:,�� '�t�f 7�/�n''�1���`�= ��f r�'�� , <br /> Da;e Back���aler Prevsn(ion deaice(l3�iJD)wzs inslalled:_��,�5 Deie if�is (orm:vas completed:�� � <br /> Ins;allation Properl�' Owner Nan-e and Contacl Info:��]���.C1.?I—� 'v`��,�2-1�`�s ; <br /> � ��^ �, �_i—��>(;r"P�" � ��(�� � <br /> Prcperty Address: ���- ,.�—�`2�-_` "' - . — <br /> Prednstallation Insoection Checkfist: � <br /> l�ll items must be checked 'Ves'in�rder for a➢l�✓D!o be considered for insfallatror � <br /> Is:here z basemeni or level of U��e house ihat is at or near assumed selver main elevafion7 �Yes �`J No <br /> Nr;; �here tizlures in the house located belcr,�Ihe upslream se�ver marhole rim elevat!on?� Yes ❑ ido <br /> Is 'he side see�er currently UNPROTECTED froro sewer backups(does nct have a BWD instal!ed)7 [�Yes ❑ No <br /> Sitc Inspection Checklist: <br /> l�;I iterns must be checked 'Ves'before inspectror is considered completea ��G� <br /> �,'�,'as side se�.�er TV insoected irom builtling lo se�ver main7 [� Yes No Condifion' <br /> Dees side sewer have at least 190 slope from tne buiiding to se�ver main? [�j Yes ❑No Describe: • <br /> Have all building sev�er drain conne�lions to Ihe side sev:er been identified and locafed? (�Yes ❑No : <br /> �;ave all property storm drai�aae conneclions to the slde sewer been idenli(ied and located? (`�Yes ❑ No ; <br /> Nas property been evalu2ted for drainage deficiencies with fintlings communic2ted to property ov:ner? ��j Yes ❑ No • <br /> Installation Details: - <br /> 1'�!hal type and brand of D�A'D�,vas installed at this site (Ciean Check BWV, Grinder pump, etc.): ^ ' <br /> v:'nere was the devlce installed (general descripfion,altach map)? c�7�f'('��C'i.G����-5���=-�-�=— �' <br /> — j <br /> :?�as lhere any other sewer or storm drainaye��:or completed in con;unclion �vilh ihe DVVD work7 Is so please describe: _ i <br /> , � <br /> - — — - ---_ - C11�_ --- <br /> Installation Checkiist <br /> ;�-e 211 do��mspouls and sile drainage disconnecled from upstream o(lhe BVVD? �1'es �_� No Commenfs'_ <br /> Cnes BIND posiGoning meets minimum slnpe requirem�nl of >190? '_Yes j� No Commenls:__ <br /> Can B4VD be pulled out(or inspection and maintenance atter loosening thumb scre���? ��Yes ❑ No <br /> Is (3NlD !ocked into the proper ��ition and ihumb screw�Iightened? [�Yes ❑ No <br /> Grcle the BN.�D cov�Joalion cover(la,ddscape area)1 tra(f;c loa�i L•earing cover(dnve surface)I access hatch (builm,ngj <br /> 'as properly ov��nur sho�vn Ihe local' n of lhe installed B�UD7 �Yes ❑ No Comments: _ _ _ <br /> rr�periy0�vner'sS�gnature: ccCc, ''�' "�- � ate: � - ,�-� -/� _ ' <br /> nslaller's Siynafu��� � - ` _ Date: ; � Z�J_ L_�._.— <br /> �U �itevisiorc Z 1 f�iday, Sep tem b e r ]2, 7 013 <br /> u ' <br />