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E�AGirC1i�►'A i cft PRE�'EfV�'i I�f�l Q�Vi�� F�RI�L <br /> � INSTAL.L�TIQ��i CFbEGK�LIST <br /> nslallafion Company �dame and Contact Info _��,N r r f-�sn�:�!�� _ <br /> / I _ <br /> )ate Backwe�er Prevar.tion oevice ;BVVU) �ras installed: I Z"� ,� Date fhis form �vas completed:� �"� l 1 <br /> nstaliaiion Propery 0�•rner �Jame and Confact I�fo: �� I iL.l' i�}�_l1{��U?�1 � _ <br /> 'roperty Address: ; �,'-% � 1ZC= �-��= -t_ �l_�,1� {-i�,-{J --� — <br /> 're-Installation Inspection Checklist: <br /> Ili itams mus( be checked Yes'm orner ior a BV✓D to be conciderr;d �or installat�or <br /> � ihere a b2sement or IevE'o(Ih� house ih;, is at or near assumed sewer mam eleva'ion� �/1 Yes �I �Jo <br /> ,re tnere f�xtures in lhe house located bel�a,the up�!�--:^. sev�er manhole rim elevafie �?(� 1'es ❑ No <br /> ; tne side se�ver currently UIdPROTECTED from sev:er backuns (does no! have 2 BIND insialled)? [�'�'es (� �!n <br /> ite Inspection Checklist� <br /> 11 rtems r�usi be checked 'Yes'be%re inspection is considered complete <br /> Jas side sewer TV insp�cted from buiidina to sevrer main? �"Yes ❑ �Jo Condition. ___ <br /> oes side sew2r have at leas� 19b slope from the building to sewer main? „ Yes � No Descnbe: <br /> a+�e all building se�ver drain connections io lhe side sev+er been ideN�Sed and locaied? I�Yes ❑ No <br /> ave all property storm drainaae connections to the s�de sev;er heen identified and located? Q Yes ❑ No <br /> ac propert)� been evaluated `or drainage de(iciencies �ti�ith findings communicated to property o�vner^ �� 1'es ❑ t�o <br /> stallation Details� <br /> 'ha� tyoe and brand o( BWD aras installed al this site (Clean Check BVVV. Grinder oumo, etc.): C-� l�-�-1'l C.^ln-t � � <br /> 'here was �he device inslalled (general description, atlach map)� t�' ��-I 5i{;�.1 , ���-i;�n..a-�_ <br /> as ihere an��othe�sewcr or slorm drainage work como!eted in conjunction ��:ith the BIND werk? I5 so please describe: _ <br /> ; lCi . <br /> stallation CheckGst: � <br /> e all de�vnspouls and site dr,�nage discenn;cled iro^� upsirezm e(ihe BI��JD? j� Yes L; No Co�n��isnis _ <br /> �es 014�D posiUoning meels minimum slope requ��ement af >?°4.? �Yes ❑ Nn Ccmmenis <br /> ;n BVVD be pulled out for in;pec�ion antl maintenance ailer loose;��ng lhumb screw% � Yes i 1 No <br /> Bl4�D locked into the r o 2r o�siiien2fld thumb sae�,v !ighlened? [✓�Yes ❑ P!o <br /> �cle the BGdD cover irlie.�ii2n �over (lanoscape are��t;raKc Ioad b�aring cover (drive;��r'ace) I acce�s ha;ch Ihuildinn) <br /> — - . <br /> :s prope�iy ov;ner sho�;;n ,he loczlion of fhs �nstalled BWD'% [rl'es ❑ No Comments <br /> �perty Oarner's Sig�ature�� ��_ Date, Z � 7 / Z� l ` _ <br /> , <br /> �%�>�� /� , �-: �Z��,�! � � �. <br /> ;ialler's Signature �-- <: �_-7�c__c�f ,_ C Date. �-� "/ /.;j <br />