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��c�v�-��� P�������o� �a���c� �erv�►� <br />��s�r���_����a� �����c�_��� <br />._._�-�----- — �_� - ------.-------- --- ---- <br />InstallationCompanyNameandCont2ctlnfo: I'i0G1� ���„�,h'� �{'a� 7C,U �f���, <br />Date Bac�tvaier Prevention deeice (BIM�) �r�as insfalied; 7'��a�e this form �n�as wmp!eted: �"�� �S'� <br />Insialladon Property Ovrner R'ame and Contacl Infu: �r �(y �—: ��, ,� 4 6 �r� �� � <br />Prope ;ry Address: __� ���- I`l �,�,,,.�` 1 N-,�— <br />Pro•Irstallation Inspection Checklisi: <br />AN iier,�s must be checked 'Yes' in order for a 5lND �o be considered forinstella6on <br />is �hzre z Lasemeot or levei o� the house that is at or near essumed see;er main eleva� on? �i Yes ❑ No <br />.�re there nx:�res in the heuse locsied beloti:� the upsVeam seticer manh�le rim elevation7 � Yes ❑ i�o <br />Is the side s2u�2r curently UNPF;OTECTED frcro seti:�er back.ps (does not ha��e a BUVD iasteiled)? [�] Yss ❑ Nc <br />Site Inspeciion Checklist: <br />AI,' if�ms must 6e c;ocked 'Yes' beia2 inspecion !s considered con, plete <br />+.�Vac side sa!ver N inspe� ed rrom buiiding to sewzr m2in? �i Yes ❑ I�b Condition: �-�S� ��^" �'Y �""`�" �'j'G�j.� <br />Dces side se:ver have at least 1% siece frem the tu�ding to ser;er �nain? Q Ye= ❑ No Descrite: <br />Have sli buildir3 sev,er �Irain conne�iionc. to the side sewer baen iden5eed and lo�?ed? � Yes ❑ No <br />iave all o;operp storm drainage conneciions io tne sitle setiver been iden5f=_d and Iecated? �] Yes ❑ No <br />Has prooe�}� been evalue;ed for dr�inage deFicizncies with fiodings communicated to prope�ty ov,�ner? � Yes ❑ I�;o <br />Installaiion Details: <br />UJ�iat tyFe and hrand oi BVdD ti��zs installed at l��is site (Clean Cheek 8'i�N, Grinder pump, etc.): � 9�z �<< <� v� ��--�- <br />VJhere was ihe devlce inslalled (generaf descrlption, attach map)? %�� s-c. �� <.-.l� �_ __ <br />':1'as there ar,y other sevfer or stortn drainage work compieted in conjun�tion �vith the 6WD �•re�c? Is so plesse doscrlbe: <br />Insialialion Checltlist; �� <br />Are all doe:nspouts and site drainage disconneded from upstream of the 614�D? '�J Yes ❑ No Comments <br />Dazs BVUD posifinning meets minimum s!ope requiremeni o� >1°/0? � Yes ❑�!o Commenis: <br />Can BV�'D be pulled cut for ir,spection and maintenance after loosening lhumb screw? .��� �o <br />Is BVJD iociced into the proper positlon antl ihumh scree; tightened? �]�s'�] No <br />Circle the BIND cover. irrigation cover (lantlscape erea) / Ua�ic load beering crover (drive suriace)1 aaess haich (buildingy�rl <br />VVzs propery o��,�ner shavn the IocaUan of Ihe installed B�1�D7 �] Yes ❑ No Coinments: <br />Propert; 0�•dner's Slgnature: <br />Date: <br />lnslallers Signature: !� %�/�--'— Dale; 7— ����i� <br />aevision: 2 1 Monday, Szptember 15, 2014 <br />