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,:;, ;;. � <br />�� <br />�a���r�� ���������� ���ac� �i��� <br />96�5��� �.A�°9�� CFiE�FCLIS�' <br />Installa�ion Company Name and Comact Info: M vz�� I�l�n w� ��;11 y �-( s �= 7�U -- � 3� c <br />Dale Backw�,ter Prevention device (BWD) �vas inslalled: G-�-� S� Date this iorm e�as completed: �-� � �� <br />Insfallalion Properly Owner Name and Contact Inio: 2� �� k N�. i h 2 0� �2 � 7 337`� <br />Proper�y Address: � �1(j �% I�, �'� Sa' �_' „--c,�{d l <br />Pre•Installation Inspection Checklist: <br />All items must he checked 'Yes' in order for a BIND to be considered for installation <br />Is ihere a basemenf or level oi the house that is al or near assumed sewer main elevationl �Yes ❑ No <br />Are there fixfures in the house localetl below the uosfream sev�er manhole rim elevation? � Yes ❑ No <br />Is the side se+ver currently UNPROTECTED from seiver backups (does noi have a BWD installed)? � Yes ❑ Ido <br />Site Inspection Checklist: <br />Afl items must be checked `Yes' be(ore inspecfron is considered complefe <br />1Nas sitle sewer N inspected irom huilding b sev,�er main? � Yes ❑ No Condition: S�'�i�� �T JQ�� /���,,,,,�o� <br />(��4�'L <br />Does side sewer have at least 1% slope from the building to sewer main7 �Yes ❑ No nescribe: <br />Have all bulltling sevrer tlrain connections lo the sidE see�er been identii��d and localed? �Yes ❑ No <br />Have all property storm drainage conneotions to the side selver been identified and locaied? �"Yes ❑ IJo <br />Has properfy been evaivated for drainage tlenciencies viiih findings communicated fo properiy owner7 � Yes ❑ No <br />Installation Details: <br />1Nhat type and brand of [iWD was installetl al lhis sife (Clean Chock BWV, Grinder pump, etc.j: ��� ���� �- �� <--�^-' S:w� <br />Where v�as the device Installed (general descriplion, atiach map)? {�ic-r�<-�J- �..-1tir c�%�Y� <br />�A�as there any oiher �e�ver or storm drainage �rork com�� j�i conjunction edifh the fiVV� tvork? Is so ploase tlescribe: _ <br />(h <br />Installatimi Checldisf: <br />Are ail downspouls antl site tlrainage disconnected (rom upstream of the BWD? Q Yes ❑ No ('ommerts: <br />Does 8WD posilioning meets minimum slope requirement of >1%?r]a'es'�No Comments: <br />Can 6VJD be pulled out tor inspeclion and maintenance after loosening thumb scre�:�� Yes'[J No <br />Is aVJD locked into the proper posilion and Uwmb screvd ligh�ened? .� Yes"r1 Ro <br />Circle ihe BWD cover: irrigalion cover (landscape area) ! SraNic_lo�dbearing cover (drive surface)1 access hafch (huilding) <br />UJas property owner sho��an the location of the insialled B1ND'? � Yes ❑ i�ln Commenls: _______ ___ . <br />��ropWhy Owner's Signature� Date: <br />Insiailers Signature: ��`��—�"� Date: <br />Revision: 2 1 Monday, ;eptember 15, 2014 <br />