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:� <br />�3A�����°�R �R��B��T'��N ���/IC� FQ�9AL <br />��IS�'6���A�"b�� �Ii�CK�.9�T <br />Instailation Company Name and Contact Info: M�e,� 1���,'^ ��' ;� y �-j ;� )=]�,U � d 3� c <br />Date Badwualer Prevention devica (BU��D) �•aas inslalletl: S'�� y j� �ale ihis furm was r.nmpleted S-,� 7-7 f <br />Inslallation Properiy Ovdner I�ame and Coniact Inio: �✓��+�. (S c Z,c 11 �/2 S- ;I'�c� 7C�, <br />Property Ndtl ress a U 0� (/,'r y M r' c, � v-�- <br />Pre-Instailation Inspection Checklist; <br />All it enu must be checked 'Yes' in order (or a BIND lo be considered !or instalfation <br />Is there a basement or level of the house thal is at or near assumed se�ver main elevation? [� Yes ❑ No <br />Are ihere iixtures in ihe house localed belov; ihe upstream sevrer manhole rim elevalion? � Yes ❑ No <br />Is ihe side se�tiro, currently UNPROTECTED from sewer hackups (does not have a BWD installed)? (�Yes ❑ IJo <br />Site Inspectio�� Ghecklisi: <br />AI( items must be checked 7es' 6elore inspeclion is considered complete <br />N�as slde se�ver TV inspecled irom building to sev;er maln7 ,� Yes ❑ f�o Condition: �TLU � <br />Does side sew�e� have at least 1% slop� from the building to sevder main9 ��Yes ❑ No Describe: <br />Nave all building se�ver drain connections to the side se�ver been identi!ied and localed? [�Yes ❑ No <br />Ha��e all property s!onn drainage connec�ions to the side so�ver �een identified and located? �Yes ❑ No <br />Has propery heen evaluated (or dminage denciencies wi�h findings communicaled to properiy ovmer7 (j� Yes ❑ tJo <br />Installation Detalis: <br />1Nhat type and brand of DWD vaas installed at this sile (Clean Check BWV, Grinder pwnp, etc.): z��j��' f f��� �'���Z <br />lJhere aras Ihe device installed (general descrip;ion, atlach map)? (�� c c��-� � a� <br />Vdas there any ofher sr.r,�er nr storm drainaye work compl��yr.onjunclion with the BWD vrnrk? Is so ploaso doscribe: <br />�� <br />Installalion Checkli�t: <br />Nre all novrnsi�outs and site drainage tlisconnecfed irom upsiream of lhe BWD? �j Yes ❑ No Commenls: <br />Does BWD pasilioning meets minimum slope requirement of >1°/a7 �S� Yes ❑ No Comments: <br />Can BVJD be pulled ouf for insper.lion and maintenance after loosening thinnb scret�a? L i'es ❑ No <br />Is (3WD locked into ihc proper position and ihumb scre�v liyhtened? [).l'e5 [] ��o <br />Circle Ihe BUVD cover: irrigalion trover (landscape area) I �raffic load bearing cover (drive surface)1 ac.ess halch (building) Nf� <br />Was property o�vner shoean Ihe location of lho installed DWD? �] Yes ❑ I�o Comments: <br />Property O�mer's Signaluie: _ Date: _ <br />Insfallei's Signature: �Tl� ��'-- Dafe: S^'.�") -� J'� <br />Revision: 2 ] �ianday, Sep�em6er SS, 2014 <br />