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�u4fxsa54d,R,lgn ED: 2+kdd.4�EF-42�f�'•&P'a�7-97C2�AYA�C3E3Z£4369sM <br />3 ' �" �. '� :;-� �.:_... . �;: ;��,: = ,,�:: <br />�5 � <br />�, <br />i.:ti' G i� `� '.�-�Y�! C:. v <br />Instailalion Company Name and Contac[ info�.a_r� _.� ' �"` ��'•`_Lt �1;L� t,�; <br />Da[e 82ckwal�r Preveniion device (BVYD) was insfalled. ra� Date Ifiis forrri was <br />�— � <br />InsfallaUan Properiy Owner Name and Contact Info; `��� � i' �.� <br />�� <br />Properiy Address: <br />Pre-Installation Inspection Checldist: <br />AII items must 6e ch2cked 'Yes' in order for a[3Wb io be considered for installafion <br />y �-- �.��.� <br />Is there a basemeni c�r IevFl qflhe house that is at or near assumed sewer main eIF vatfon? �'Yes ❑ Nn <br />Are there fi>dures in the hnuse located belov� the upsi�eam searer manhole rirn slevationl �'es ❑ Plo <br />Is tha side sewer currently UNPROT�GTED from selver backups (does not haae a BWD installed)? [�les ❑ No <br />/ <br />Site Inspectlon Ghecklist: <br />AI! items mustbe ciiecked 'Ys.s' hefore inspectiott is considared ca���ple�e l�pJ� � { <br />tNas sitle sewerTV irispected Emrrrbuifding t� seurer main? �s 0 No Con�itlon; t �� <br />Does side se4ver have ai isast 1°'fl S(ope from the building tn sewer main? �Yes ❑ N3 Descnbe; <br />Have a(I tiuitding sev✓er drain cnnnecticns to ths side sevoer heen ideatified atid tocated? [_c�'es ❑ No <br />Have ail ptaperty storm drainage connecfions io the side seiver tieen identified and lo�teci? �(es ❑ Na <br />Has propety been evaluaied for drainage denciencles with f ndir:gs eomirwnicated to properly ownet? [�cs ❑ N� <br />f <br />Insfallation Detalis: <br />Wfiat bjpe end 6rand of BNJQ �vas insiaCed at this site (Ciean Checic SWV, Grinder pump, eta): `7 <br />Where vtas {he device inslalled (general descripfion, aifach map}? `3 __ (,R �� <br />VVas there any other sev;er or stomi drainage wo�k camplete;d im m�junction �roith th,e, ,B,VV�o work? Is so please describe: _ <br />�,%( F Y �-{' <br />Installation CheckiisL- <br />Are all dutvrupou�s aad sife drain2ge disr.ormected (roin upstre�m nf ihe BWD? [�'es ❑ No Cammenls- _.._ <br />Does BWO positioning meeis minimum siape reyuirement o( %1%? �es ❑ No Camments: <br />Can BWD be pu{led oul for insper.tion and maintenance after loasemng lhumb screw? �.la'es ❑ No <br />is BWD locked info the pro�p�pasitirnra d thumb screw tightened? �Yes ❑ No <br />Cirole the pWD cov . irri9a!io�over � dscape area} / Vaffir.load bearing cover (drive surtacr-j ! access hatch (�ufldiny) <br />bUas properfy oevncr s oam tha `��2�t�led BWU? (�'es ❑ IVo Comments: <br />yi l <br />Property Owners Signature: �_. <br />R9R018 <br />Installers Signature:.._ <br />Revision� 2 <br />i <br />E....._........__. ...._ . .. ___. . ..... ._ .. <br />...__.___________..........._.._.. . <br />Oate: <br />9I28/2016 <br />oate: c�-- <br />(riday, SeptemU�r 12� 2014 <br />