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� P ,��� .�� '•� <br />�'e-',l?'s^� <br />' �' -' <br />L������ !f �� E� �p� 17 ��E�i�11�{!� <br />������ ����� <br />����������� ���������� <br />tns�alta�ion Company �r�me anci Con�ac� inin: �t�� �( <br />�aie �ackwaier F'reven�on device �t� ,� • �r`, h'n � � �" 7�� ��6� <br />� ) as ins�affe�; <br />fnsraflafion Pro e r date ti�is �4tm v�as compieied; ��"�� �/ /�� <br />� �3 Owner Name �nd Con�act [rtio: r� <br />�ropErry Aadr�ss: �� �2 --° f-( 2r� 3��7 r. � 0 3 <br />� �< `�,, �. <br />f�t����ns��{la�ion Ir�s�aec�a�a �h�ckifst: <br />�11 ir�ms mus� he chec��ed `Yes' in order for a B�/p �� ,�� �ansidered iarinstallation <br />fs �l�e�•a a basemeni �r l�ve! oi tf�e 1�ouse tha� is at or ne�r assumed s�wer mai <br />Are there ��#ures in rhe 1�ouse l�cated below �te �ps�rearn sewer rnanhole rim eleva�i iion? �] Y�s j] EVa <br />ls fhe side se�+ver curre��ly UNPRp i�CT�� �r�m sewer backups �oes no= o�� � Yes ❑�o <br />�i�� t�rs�e�iior� ��e��1E�: � t��YB a�i�� Ii15T'd�IEG}? ,�j Yes ❑ nio <br />A!! iterns ntusf be ch�cken' Yes' berore inspeGtia� is Cortsi�er ed com let� <br />Utlas side sewer �t� inspeete� from building i� se�<<er main? � <br />Does side set�ver ha�,re ai least �°Io slope irom �h� buifdin to se� ��s (� (lo �o���;a�: �a� ��e k�`' <br />I�iave all buildin� set�rer drain connaciions io ihe side sewer been�d n�ii�sd a,��d a� ��o Descnhe: <br />Ha��e alf praper`iy siorm drainage cannec�ions to ihe side sewer �een iden�ied and focate �� ��� <br />Has proper�y been ���[ua�ed tor drainage dsnciancies wiih �►ndings communicated fio ro e�"�� ❑ Na <br />����[d��ior� D�"rai��: � p �3' �wner. � Yes � �lo <br />INhaf iype and brand of BWD was insialied ar fhis srte {Ctsan Check B'i�Rl, Grinder pun�p, �tc.): �/��-� c L t � <br />l�l�here ��+as ihe de�lic� insiai(ed �gen�ra� descripfl�l�, aifach ma ? � c <br />P)- 1=�rv �� �,.�� <br />Vvas there any azher sela�er or storm drainage work co ple�ed in Gon un�ion W h , <br />� i � the Bt�JD +rovrk? !s sQ please descnbe: <br />{n�LQP�a�ian �I��cfzfi�: � . .^. <br />Are af1 d�wnspouis and s[ie drainage disconneatec# �rom upstream Qftf�e Bt�11D? �'Yes ❑�o Cornmen s <br />�oes B�N� positioning mee� r�in�m�m �[op� rec�r�i�emsnt o� }� °lo? � Yes ❑�a C�mm�n�s: �. <br />Can 6�1�,i �e pu!#ed au� ror inspec�an and mair�ienance af�er Io�sening ihumb screv�? ���s ❑�o <br />fs BUUD IOCIS2d fi1fQ �g pr0 e� osition and ihumh screv�T �ightene�? �Yes L] No " <br />Cire[e the BIND cover irri euan_�v r�landscape arEa} 1�'affi� load b�ar�ng cover �drive s�tr€ace} I access haich �uild�na <br />Vtr�s prap�r'iy owner shown �f�e Iocatian of the instalied �WD? V t �} <br />� � ❑ �n Cornments <br />Pro�erty Qwner's Sigr��t�are. <br />L7afe: <br />1nsi�(!er's Signature: � , � <br />Date: S ._ � C; i (., <br />Revision: z <br />� IVfonday, Scpter�ber 15, 2A14 <br />