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i <br /> BACKW , ..EVENTION DEVICE FINAI. � <br /> INSTALLATION CHECKLIST I <br /> ; <br /> 1 1'►'1�f i Cat'1 �,X'� � �, ^!- ��'�dr. <<�:�'� L LG � <br /> Ins'al aticn Company Name and Co^tac!Into:�P r.C��� � �� �,y� '�-:! -L�.'%S�if�i�'Cl� 2F� s)'�!„Y, i���iJ_S„� I <br /> Uate Bacti�ti�ater Prevenlion device(BWD)�vas installed .�a�►]�__Date ifiis form was completed �,�11�5 . � <br /> nslaliat�on Property Owner Name and Contact Into ��,�(�_ -�- �)PYlbl�dr_ �'�'�'LL'}�c4�f. I <br /> ProaertyAddress ���_�Y? c�Ct�( _ _C>�- �J�U�L�S?� . �c�dC'? I � <br /> =-f-- - ' <br /> Pre•Installation Inspection Checklist: <br /> l,ii dems must 6e cher.iced 'Yes'in nroer Inr a BWD l0 6e considered foi insiallation <br /> !s t�ere a baseme�t or level o!the hcuse that is a; or rear assurred sewr.r ma n elevat�on?[�Yes r , No <br /> Are tliere fixtures in the house located be�ox;he ups'ream se��ver manfioie nm elevafion?�yb�es �J No I <br /> is `he side sewer cur�ently IiNPROTECTED from sewer backu�s ;aoes not have a BVJD mstal!ed)?�Yes ❑No ! <br /> Site Inspection Checklist: I <br /> AI;items r���st be checked'Ves'be!are irspecGon is co�sidered comple'e E <br /> � I <br /> Vv'as s�de se�ver TV insper.ted trom building !o sr.we�ma n'? �1'�ti, 'es ❑ No Condition __ �� _ __ i <br /> Does side sev,e�have at leasl 1%slope from Rie build�ng to sevrer maic? [�Yes ❑ No Descr�he: I <br /> Have all boilding sewer dram connections to the side sewer been idenfiGed and loca;ed7 C�Yes ❑No � <br /> I <br /> t-ave all properry storm drai�aae connec(ions to the s de sewei been idenf;fied and located? �Yes [] No � <br /> has property been evaluated(or dra'�nage deficiencies�uth findings c:ommun�ca;ed to property ov,�ner� �Yes (1 No ! <br /> � <br /> Installation Details� � /'� <br /> VVhat type and hrand o}BWD v�as i^stalled at ihis sde (Clean Check BN'1', Gr�ntler pump,etc.) �' '� �c.� � <br /> � , � 'l,' ��_ i <br /> l'Vherr. was t �e de�ice instalied (yeneral descnp�ion, atla�7 map)' ��_f�F[l�'�'�R c 1 . f <br /> - -- --- -- i <br /> 1'Vas lhere any other se�ver or storm drainaye wor!c r.ompleted in coniunctiun w!Ih the BWD�vork? Is so please des�nbe. .__ <br /> --- --- — -- -- - --_ _ 6� ► 4' -- i <br /> Installation Checklist: � <br /> Are all downspouts and site drainaye disconnected (rom upslream o`lhe DIND? �'Yes 11 No Commenls i <br /> Loes �'4ND pasitioning meets minimurn slope requirement oi>1°/a7 �Yes U No Gommrnls ____ _ <br /> j <br /> i <br /> Can BW�he pulled out lor Inspectioo and mainlenarice afler loosr.ning Ihumb scre�v'7 �.�Yes � No <br /> Is (3WD iocked inlo Ihe proper position ard ihumb scre�v bqMened? � Yes ❑ Nn ; <br /> Circle the RWD r.ov irrigafion cov�t.(ia�iscape area)1 tratlic load beanng cover(dnve suriace)I access hatch (building) � <br /> �—"" <br /> 11�as property owner shown Ihe IocaUon o(the insta!Icd Q D� f�Yes ❑ No Commenls: _ , <br /> ����°�"--- � � ��^�� " �� � <br /> P�operty Owner's Signalure . (7' __ �ate�_ <br /> Insta�ier's Signalure�--. -- .---_----- Date: _�'Z (. ` � _ i <br /> i <br /> Revision. 2 1 Friday,Septrmber 12, 2014 <br /> i <br /> � <br />