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_ � �A�K�!'�!`���; ��R��J�:P��'6�ft� ��i�'!CF �IN�1L.. <br /> � �- 4h�:�"E'�i�.�A"�ION ��i��K��a�� <br /> Instailatlon Company �ame and Conlact Info:� ;� /�!_�� <br /> Dale Backv;ater Prevention de��ice (BWD)was installed: I I Z[(�� I ;S�Dale Ihis form�•�as �ompleted:� <br /> Insiallaiion Propery Owr.2r Name and Con act Info:� 3L� _ <br /> Froperty Address:��Ff � i'T��le��� <br /> Pre•lnstaliation Inspection Checklist: <br /> AI!items must 6a checked 'Y'es'in order for a BINU to he considered lor inst21l2tion <br /> Is there a basemeni or Ievei o(�he house ihat is at or near assumed sewer main etevatlon? [�]Yes ❑ ��'o <br /> Are there iixtures in lhe house loca�ed belo�,v the upslream sea�er manho�e rim elevation?[�Yes ❑ No <br /> I; lhe side see�er currently UNPROTECTED from sewer backups (does not have a BI�dD inslalled)7 [�Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must 6e checked'1'es'before�nspzclion Is con�idered complete <br /> lVas side sev+�r N inspected irom tullding io sevrer main? [�`fes ❑ No Condition: <br /> Does side se�ver h�ve at least t°o slope irom the huilding to sewer main7 �..'Yes ❑ No Dsscnbe: <br /> Have all building se�•:er drain con�ieclions to Ihe side setver been identified and located7 �]Yes ❑ IJo <br /> Have all property storm drainage connection�to the sids sewer heen identified and located? [�}Yes ❑ No <br /> Has property been evalualed for tlrainage deficiencies wiih findings communicated to property e:vner? �Yes ❑ �\o <br /> Installation Details: <br /> U��hat type and brend of BWD was installed at this site(Ciean Check BWV,Grinder pump, etc.): l�Dl�-4'Z �-�Q.Gk— <br /> 11'here was the device in�ial!ed (general des�riplien, atlach map)? j'J I,t..j"' � �`o�_���Q� <br /> v <br /> Vdas there an}-olhar see;er or sterm drainaye v;ork �ompleted in conjunction w,ith ihe BWD vrork? Is so please c;escribe:__ <br /> �1,(��-- <br /> Installation Cheeld�st: <br /> Are all downspouls and site drainago disconnecled from ups�ream of il;e BWD7 �Yes [J No Commenis�___ <br /> Coes BWD posi}ioning meets minimum slope requiremenl of�1°57 �Yes ❑ ��o Comments: __ <br /> Can BVvD be pulled oul for inspectlon and maintenance after loosening ihumb s�re��a?�Yes ❑ I�o <br /> Is BWD locked into the proper osi' n andl�lu nLb s�tv tightened? (�'es ❑ tJo <br /> Circle the (I�UD cov • ' Lc�on cov_ er(lan scape are I iraf ic load bearing cover(drive suriace)/access h2tch (building) <br /> VJas property o�vner shovm the locaticn of the installed BtiVD? ��Yes ❑ No Comments <br /> PropertyOti�+ner'sSignature: ��'?��7'�-Q���� ��"��'' Date: � Zl��s <br /> Instailers Signal�i>�_��-_=__�l/—/�i -�� Date: / �2 JI/�' _ <br /> - .— v - <br /> Revizlon: J 1 Friday, Septembpr 12, 2014 <br />