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i <br /> I <br /> i <br /> �A�;NC�iiAl'�R PF2EV�M1'lQiV L��ViCE FI�IAL , <br /> � 6N�1'A�,�.ATl�N CHECKLIST � <br /> � <br /> _ , <br /> � <br /> Installation Company Name and Conlact Info: M �e-^ I��H�������y �-(� �� ]�U-k 3�c � <br /> Dale Bacin•�ater Prevention device(BWDJ v�as installed: ��(-�i-1_!�Date this form was completed �-5'�� i <br /> Installation Properiy Owner Name and Confact Info: V�, ( w+�/r �4�4� � <br /> Property Address: a �I I � � �Lvc �`,. L l.�v-� ! <br /> Pre•Installation Inspection Checklist; i <br /> All items musf be checked'Yes'in order lor a BV✓D to be considered for instaliation i <br /> Is there a basement or level of the house that is at or near assumetl se�ver main elevationl(�Yes ❑ No I <br /> Are lhere fi�Aures in the house located below Ihe upstream se�ver manhole rim ele��alion?�J Yes ❑ No I <br /> Is the side sewer currenlly UNPROTECTED trom sewer backups (does not have a BWD inslalled)?�Yes ❑�'o i <br /> Site Inspection Checklisf: I <br /> All items must be checked'Yes'before inspection is considered complele i <br /> lNas side se�ver TV inspected from building to sewer main? �Yes ❑No Condition: au � rwk a 6u G.��t I <br /> Does side sev:er have at least 1%slopo irom the building to sewer main7 �Yes ❑No �escribe: <br /> Have all building sewer draln conneciions to Ihe side se�ver been identified and localed? �Yes ❑ �do I <br /> Have all property storm dramage connections to lhe side sewer been ideotified and loealed? �J Yes ❑No <br /> Has proporty been vvaluated(or drainage deficiencies with Mdings wmmunicated to prope�ty o�vner9 (,y�Yes ❑ IJo � <br /> Installation Oeteils: � <br /> i , <br /> What type and hrand o(DWD�vas inslailed al ihis site(Cie2n Check BWV,Giinder pump,etc.)� C�C�.. �4 e1e I <br /> Where�vas the device installed(generai descriolion, atiach map)? ���- v cr Z <br /> { <br /> 1 -- - ---- , <br /> — ----- ' <br /> Was ihere any olher sewer or storm drain�/work completed in conjunction with the BIh�D work? Is so pinaso describe:_ � <br /> - ----- --- --f-+'---- <br /> Installation Checklist: <br /> Are all downspouls and sile drainage disconnected(rom upstream ol thc DWD? (�j Yes ❑No Comments: ___ <br /> Does BWD positioning meets minimum slope mquirement o(>1%? �k]Yes (]No Comments: <br /> Can BWD he pullr.d oul lor inspection and maintenance efter loosening thumb scre�v? �Yes ❑No � <br /> Is BWQ locked inlo ihe proper position and ihumb screw tighlened7 �Yes ❑No i <br /> Circl��he BWD cot�er. rigation c er((andscape area)1 iraffic load bearing cover(drive surface)I access hafch(building) � <br /> INas property owner sho�vn the location of ihe insfalled BWD? �Yes ❑No Comments�______ <br /> Property Owner's Signalure: Date: , <br /> Installers Signalure: _ /�— Dafe� u�5`—� � � <br /> Nevision: 2 1. Monday,September 15,2014 <br /> � <br />