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�A��1i�A.'��R ��t����4 i C�N t��V6G� �ii��,L <br />-� �1���'�@_Lf�,�'lG+E� CFQ��E��E�F <br />Inslaliation Company h'amo and Contzcl In`o: _�`� iJ�tll ���,r,h %Gy � S �7 � O fj <br />Dals 5aclnvaler Prevenlion device (BWD) �;�as instal!ed: �'S- ( S �date this form �ti�as comoleled: �- 5' �S <br />Inslallation Property O�vner tdame and Contacl Info: nw �� C' j-c„ ti�lv� Li � S- '% S O{�� � r-� <br />Ptt�7CflVAddfeSS:��ILf l%i�trGll�/1 I y � <br />Pre•Inslallation Inspection Checkiisi; " <br />AN items musi be checked'1'es'rn order for a BWD fo be considered forinstalistion <br />is lnere a basement or level of the house lhat is at or near assumed se�ver main elevaiion? � 1'es ❑ No <br />Are there fixlures in the house localed b21o�v the upstream sewer manhole rim eleva6on? � Yes ❑ No <br />Is the side �etiti�ar currenlly U�'PROTECTED from setiver backups (does not have a BIND inalalfed)7 � Yes ❑ No <br />Site inspection Checklist: <br />A(1 items musf be cli?cked 'Yes' be�ora inspection is considered complete <br />l4'as side se�ver TV inspected from 6uilding to sewer main? �� Yes ❑ No Condition: Lrw � <br />Does side see:er have at least 1% slopz from the building to sevrer main? �j Yes ❑ No Describe: r•., d,'�� <br />Ha��e etl building sev;er drain connecti�ns lo fhe side se��:er been identified and Iccated? �Yes ❑ ido <br />i!a�e all property storm drainage conrections to the side sewer been identified and located� �] Yes ❑��'o <br />I; ,: property been evalualed tor drainage defciencies tviih findings commun'cated to property oe;ner7 �Yes ❑ tdo <br />Installation �etails: <br />V��hal fype and brand of BI�dD tvas installed at lhis sile (Clean Check f3WV, Grin��r pwnp, etc.)� C,�ti:,n Ll..�.� k <br />VJhzre e�as ihe device installed (general descriplion, attach map)� i�� �rui�{� U� I1nL.�,�. (,�;1- <br />o k �,�- d„ �,/ <br />Was ihere any ofher sevrer or storm drainage v:ork compleled in r,onjuncfion vrilh the �VdD e�ork'? Is so please describe: __ <br />Insfallation <br />Are all dovrnspouls and site drainage disconnected from upslream of Ihe DIND? �Yes ❑ No Commenls: <br />Does BLND positinning meefs minimum slope requirement of >140? �Ycs (] No Comments: <br />Can BWG be pulled eu� for inspection and maintenance after loosening Uwmb screr�? � Yes ❑ �o <br />Is BIND locked into the proper position and thumb scre�v tighiened? �J Yes ❑ No <br />Circle Ihe BVVD covec ri ation cover ndscape area)1 iratfic load bearing cover (drive suiface) I access hatch (building) <br />lA�as property owner shov;n lhe location oi the installed BWD? �Yes ❑ No Commenis• <br />Property On�ner's Slgnalure: Date: <br />Instailers Signature: `� Date: �� S— I S <br />Revisio�� 2 1 �ytonday, September 15, 2014 <br />