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�A�l�VV�aTE�' ����A�NTIl7�1 D�VICE �eN�eL <br />d �P�S�A�.���9�k� �Fi�CKL`�T <br />1 I'►1�ri G�,-�n �..�(��-� G�r ����de -�e��z'� L t�c: <br />Installation Ccmpany Name 2nd Contact In`o:J >�� ' L� (/i �F' �+-�%Cf• i� c� i �'Y'ls ���ti., "/IO <'?/. �,`; <br />Dale Backv.�ater Prevenlion devir.e (Bl4�D) was installed _��f C�-��j _ Date this form ti:�as completed: <br />Instal!atlon Property Ovm^r Narre and Contac' Info:.'���jf�_ �� �1 ��,��=�'� � �� <br />F'opeRy kddrzss:. <br />Pre-Installation In�r�......,, <br />All dems mushhe checked'Yes' �r order /or a BV✓D to be considered for ir,s!alfafion <br />Is there a basernert or level �r the house ihat is at or r�e2r �ssumed sev�er main eievaiion? �Yes ❑ No <br />Are there (ixtures in the house localed be!o�v (he upsiream sea:er manhole rm elevation? �%Yes ❑ No <br />is tne side sev:er currentiy UNPROTECTED from see.�er backups (does no! h.ave a 841�D instailed)7 �Yes L] No <br />Site Inspection Checklist: <br />Ail items must be checked 'Yes' before inspection is considered complete <br />!h'as side sewer TV ins�er.led irom building to sewer main� (�Yes ❑ Mo Condition _�(��[�_ ___ <br />Does side se�:�er have at least i% slop� from tlie building to sewer main? �jiYes ❑ No Describe: __ __ ___ <br />Have all building sev�er drain r.onnections to the side sewer been idenlified and Iecaled? �Yes ❑ No <br />Have all property storm drainage connections to the side serrer been idenli5ed ard located? �L'es ❑ PJo <br />� <br />Has oropery been ovaluated (or drainage deficiencies �iilh fintlings communicated to properiy oe�ner? �Yes ❑ P!o <br />Installatio�i Details: ) <br />�Plhat type and brand oIBWq �vas installed at this site (Clean Check BVJV, Gnnder pump, etc.): _� ��`� <br />Where vaas ihe device installed (general description, atlach map)? L�(� �� � �__�lx.� <br />Was there any olher sewer oi storm drainaye �vork compleled^in conjunclion v�ith the BVUD v�ork? Is so please,describe: _ <br />___ _l��SY_��— — <br />Installation Checklist: <br />Are all do�vnspculs and sile drainage disconnecled from upstream of iho BWD�7 Yes ❑ No Comments' <br />Dces HWD posilioning meets minimum slope requirernerl nf>1",�0? �'Yes U No Comments:.__ _ <br />Can BWD be pulled ouf (or inspection antl maintenance ,, ,�:r loosening ihumb screv,�? �1'es ❑ No <br />Is BWD locked into the propr.r posilion and ihumb scretv tightened? �=Yes ❑ No <br />Gircle ir� BWD rover. g�lion cover (l�ndscape area) / traifi� load bearing r.over (drive surface)/ access halch (building) <br />�� <br />l�das property oe+ner shoe+n ihe localion of the inst�lled BN1D? �}•l'es � No Comments ___ <br />Properiy Owner's Signature: <br />Inslallers Signature� _ <br />Rcvision: 7 <br />"— _ Dafe: X/ � ��ll'� �i ��. <br />?��J Date: ��/�T (,—_ <br />Friday, Seplem6er 12, 2D14 <br />