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i <br /> � <br /> �t��E��.�'E� P�����Tt��E �3�i/lC� FiPJfi�L � <br /> a. It���'�,L.Ld4Tl�� �ki���C�.lS� i <br /> �� �. i <br /> � <br /> Insfal!ation Company Name and Contact Info' M '��� I���-,����� �1 y � � 1= ]�U-b'3�c I <br /> Dafe Bacln�rater Prevention device (BWD)v,�as installed: y-e�°]-�� Date ihis form was oompleted: �/-�-5'U � <br /> II <br /> Installation Property Owner tJame and Contact Info: �e�_�✓i e�.,� t <br /> Propert,Address: a`{i� L v���--✓�. /-�-v� ! <br /> Pre-Installafion Inspectlon Checklist; <br /> All items rnust be checked 'Yes'ir. order(or a BWD to be consrdered for instalfalion � <br /> Is lhere a hasement or level of�he housz that is at or n2ar assumed sevder main elevation?�(Yes ❑ No ! <br /> Are fhere fixiures in the hou�e located below the upsfream sewer manhole rim elevation?QYes ❑ tJo ! <br /> Is the side sew2r arrently UNPROTECTED from se�ver backups (does not have a BIND inslalled)?'�Yes ❑ No <br /> Site inspection Checklisf: ; <br /> A!I items must be checked'Yes'be(ore inspection is considered complete � <br /> VVas side sewer T1�inspected from building to sew2r main? �Yes ❑ No Condition: N�e� ' <br /> Does side sevaer have at least 1%slope from ihe building fo se�aer main? [�Yes ❑No Descnbe: � <br /> Have all builtling sev;er drain connections to the side se�+:er been idenlified and localed? �Yes ❑ No � <br /> Have all property storm dr��inage connections to the side setia�er been identifed and Iocated7 (�jYes ❑ No <br /> Has property been evaluatetl for drainage deficiencies vrith findings comrnunicated to property ov.�ne�? �Yes ❑ �o ; <br /> Installation Details: <br /> 1'dhal lype and 6rand of BWD vaas instailed ai this si(e (Clean Check BWV,Grinder pump,etc.):.l(�w, �L�. cl� _ ; <br /> lNhere was the dovice insialled(general description, attach m3p)? (�f�� v� ��<k �;�-c r.t� i <br /> h��.,f-� f <br /> -- -- � <br /> l4'as there arry olher se�ver or storm drai�g���rk completed in conjunction with the B'�ND tvork? Is so please describe: _ i <br /> _ ^ , <br /> Installation Checklist: ; <br /> Are nll do�vnspouts and site drainage diseonne�ted(rom upstream of the BWD? �Yes ❑ No Comments: ____ � <br /> Ooes BIND posi(ioning meetc minimum stope requiremenf of>1%? ?�S_T Yes ❑ No Comments: <br /> ; <br /> Can Bbl�D be pulled oul for inspection and main(enan�e after loosening ihumb screw? �Yes ❑ No <br /> Is Bl�'0 iocked into the proper position and thumb s�rev��ightened'? f�`(es ❑ No ' <br /> �- � <br /> Circle�he BIMD couer: irrigation rover(landscape area)1 tr f Ipad bearin Lover �ve sur�ace)!access hatch(building) ; <br /> l4�as propert��ovmer sho�vn the location of the installed BIND? �Yes ❑ No Comments: _ � <br /> i <br /> Property ON�ner's Signature: Date: ? <br /> Installers Signalure: �%`4 � Date: �'�Z S - � � <br /> Revision: 2 1 Monday, September 15, 2014 ! <br /> i <br />