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i <br /> ! <br /> i <br /> �A����a`��6� ����6�6��°B�°9P� ���Y�� �i���. � <br /> � - 64�9����.���`@�� �F��CF��.��� ' <br /> -- — ---- —._._ _ ....� � <br /> Instailalinn Company Narie and Contact Info:N'uzn I��ti�����»y+ �/�21� ��,p-b�3C,c i <br /> Date Bacinvater Predenlion device(BWD) �vas ins:alled:S�-a?��,Dale ihis �orm was completed: �-��-� )r j <br /> Inslalla�ion Properly Owner tdame and Contact Inio: G�1 e�.� { C.�`:-��5'-< <� �f�2�,Z 3 ( v0 ?3 � <br /> -r <br /> Property Address: I�/�Z Flu./-� __f��c � <br /> ,�-- --- <br /> I're-Installation Inspection Checklisk: <br /> All ilems rnust be checiced'1'es'in order(or a BIND lo be considered(or installation ! <br /> Is there a basemenl or level oi Ihe house that is at or near assumed se�ver main elevation? �]Yes ❑ IJo <br /> Nre lhere fixiures in the house located belov�Ihe upstream sev�er manhole rim elevation?'�Yes ❑ No <br /> Is ihe side sevaer currenlly UIdPROTECTEC irom sewer hackups (does not have a BWD i�stalledj?[�Yes [] IJo <br /> i <br /> Site Inspection Checklisf: � <br /> kll iierns musf he checked'Yes'before inspection is r,onsiderad complete �,,va S �� �K ry �„ti+ <br /> Was side se�ver TV inspected trom building to sev�er main? (�Yr.s ❑ A�o Condition:•� <br /> Does side sewer have at least 1%,slopa from the building to sevaer main7 �Yes ❑No Describe: ih���N�'� <br /> Have all huiltling sevrer tlrain connections to the side seeder been identified and located7 �jYes ❑ No <br /> liave all property starm drainage connestions b the side sevfer been identified and located? �Yes ❑Ido <br /> Has property been evaluated for drainaye deficienr,ies v✓ifh findings communicaled ta properly ovmer? [�Yes ❑ No <br /> Instailafion �etails: <br /> 1Nhat type and brand oi R14'D�;ras inslalled at ihis sile(Clean Check BWV, Grinder pump,etc.): f'(�u Z (r�-,-'+,� <br /> Where�vas the devicn installed(general description,atiach map)? (�<cc•._-{-�� �,��f <br /> Was there any oiher ser:�er or slorni drainage u�rork compleled in conJunciion w�ith Uie BWD work? Is so please describe�_ <br /> --__ ._ /li�� _ , <br /> InsfailaEion CheclQist: <br /> Are all downspouts and sile tlrainage disconnecled(rom upstream of ihe 0WD? [�]Yes ❑No Commen�s:___ � <br /> Does R���D positioning meeis minimum slope requirement ol>1%7,��}-Yes�No Comments: _ '. <br /> Can BWD he pulled oul for inspecfion and mainlenance after loosening thumb screv�?,Q-1`�s�[]No ; <br /> Is f�N.iD locked into Ihe proper posiGon and iiwinb screva liyhtened? na'es"�Nn <br /> Cirr,le the BWD r.over: irrigetion cover(landscape area)!traffic load bearing cover(drive surface)I access hatch(huilding)N�fr ' <br /> !,��as properly a:aner shovdn the locafion o(lhe installed [iWD? ��Yes ❑ IJo Commenis: _ � <br /> Proparly Ovdner's Signature: Date: / <br /> Installer's Signalure:�� `/ �''_-- _ _ Date: 5 �� ���J <br /> Revision:2 1 I�4onday,September 15,Z014 <br />