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; <br /> �A.�F���`P�R 6�6���'��9�°��f� ��'161�� ��i��L ! <br /> � .� 6I��`��il�r�'a.�'a��€ ����K0�1�'�' i <br /> i <br /> - --� __�� � � <br /> Insta!��!ion Company Name and Contact Info: � �e�` I��H�^������y �-J � S — �(,U—�3G c � <br /> — � <br /> Oate Bacia�aler PrevenGon device(BU�D)ivas inslalled: (, -�'�S� Date ihis�orm was completed: �'��� ' <br /> !nsfallation Properh�Osdner t��ame and Contact Info: .Tc, ���-t- 1�S �� ,� u�, 3��-{ �7�6 ; <br /> �roperty Address: � �Z� H�y,} (�..-� � <br /> i <br /> Yre•Installation Inspection Checklist: ! <br /> All items must be checked'T'es'in order(ora BWD to be censidered forinstallo;'on { <br /> Is lhere a basement or level oi the house that is at or riear assumed setver main elevation? LS�s Yes ❑ No � <br /> Are fhere fu;tures in the house located below the upsfream sevrer manhole rim elevation?�f Yes ❑ No <br /> is the side sewer currently U(dPROTECTED irom sewer backups(does not have a BWD inslalletl)?�]Yes ❑ fJo � <br /> Site inspection Checklisf: ' <br /> All items must 6e checked`1'es'before inspection is considered cornplele ± <br /> �Mas si�o sewer TV inspected from building to selver maln7 (�Yes ❑ No Condition: �� � ���-c+� ��J��2 ' <br /> Does side se�ver have at leasl 1%sfope irom the building to ses�er mainl [�Yes ❑No Describe: � <br /> Have ail buiiding sev,�er drain connecfions to fhe side se�ver been identitied and loceted? j�"Yes ❑No <br /> % <br /> Ha�re all property storm drainage wnnections to the side setver Been iden6fed antl located? (�Yes ❑No ' <br /> Has property been evaluated fordrainage deiiciencies wiih fndir�gs communicated to prooerly owner? �'1'es ❑ tdo ' <br /> Installation Details: <br /> VJhat type and t�rand of BWD was instailed al this sile(Clean Check DVJV, Grintler pump, etc.): ������-�l ��t.� � F(w! t-�-.rc ; <br /> V�mere was Ihe device installed(general descriplion, atiach map)? d�s����b- h y �r,.lc ___ � <br /> - - � <br /> �ida,thr,re any oiher se�aer or slorm drainage work compleled in conjunr,tion\}'I�II IIIP, BWn WOfI(� IS 50�I0350 CIG6GfI�P.: _ t <br /> .____ _ __._ ...__- �—/ h"� i <br /> Installation Checklisf: ! <br /> Are all do�vnspouls and sile drainage disconnected froni upslream of the Bl�1�D? S�Yes ❑No Comments:_�` ! <br /> Does RWD positioning meeis minimum slope requirement oi>1"/�? �Yes ❑No Comments: { <br /> Can BWD be pulled oul for inspection dnd mainienance after loosening thumb scre�v�(�-Y,�"[�Nu <br /> Is [3WD locked into the proper posifion and thumb scree�tightened7 ,�-Yes I�I I�o <br /> Circle Ihe DWD cover. irrigalion cover(landscape area)I iraffic load bearing cover(dri�re surfaca)!access hafch(building)N/�� <br /> �r�ras properiy owner shoti�dn lhc location of ihe installed BWD? [I�Yes �� P!o Commenis . ___ _.._. ; <br /> Proparty Owner's Signature: Date: ; <br /> Insfaller's Signafure:��%`� _: _ Date: � ��" �S/ <br /> Revi;ion: 7 1 Monday,Septembcr 15, 2014 . <br />