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BAC@(WATEFi PREVGN�'I�R! �EVICE FINAL <br />E„ @NST/�LLd�ii°IO� �HECFCLiST <br />1 �'►'x,ri �c�zn �(��-� � �r �� ,ae �c�:x�� � � �.4. <br />InstallationCompanyNameandConlaCtlnfo:.Jr���f{iC(' tia`�,?'�✓ ���5��n'�'r%��-�C'Z����f `"�✓�"c� <br />Date Rack�vater Prevenlion deti-i�e (BWD) t:�as installed:i��,�_ Date this form was completed:���ij�(� <br />Installatioi� Property Owner Name and Contact Info: <br />Property Address: <br />Pre-Installation Inspection Checkiist: ''' <br />Afl items must 6e checked 'Yes' in order for a 8WD to be considered for installation <br />Is there a basement or level of the house that is at or near assumed se�eer main elevalion? � Yes [j No <br />Are there fixtures in the house located belo�v the upstre2m sewer manhole rim elevation7 � Yes ❑ No <br />Is the side sevaer currenlly UNPROTECTED from sevrer backups (does not have a BWD inslalled)? � Yes ❑ No <br />Site Inspection Chec�clist: <br />Aff items must be checked'Yes'before inspection is considered complete /� �_/ <br />Vdas side sewer TV inspected from huildinc� to sevrer main? �] Yes ❑ No Condition: (��C. ,�3 <br />Does side sevaer have at leasl t% slope from the building to sewer main? �Yes ❑ No Descrihe: <br />Have all building sewer drain connections to the side sevrer been identifed ar.d iocated? (� Yes ❑\o <br />Have all properry storm drainage conneclions to the side sewer been ideniified and located? [�'e� ❑ No <br />Has properiy been evaluated for drainage deticiencies with (indings communir,ated to property or�ner? �'Yes ❑ No <br />Instailalion Detaiis: <br />What type and brand of DWD v�as installed at this sife (Clean Check BWV, Gricder pump, etc.): ��� <br />Where was the device installed (general descriplion, atfach map)? ._�i� (��� ��.e..L� <br />Was ihere any olher sewer or storm drainage work completed in conjunction �vith !h,e BWD wr:k? Is so please desaibe: <br />— �U�--- <br />Installation CheckllsC <br />Are all dovrnspouls and site drainage disconnected from upslream oi lhe BWD? �(j Yes U No Commems _ <br />Daes BWD posilianing meels minimum slope fequitemenl of >t967 (�(jYes ❑ No Commenls: <br />Can BWD be pulled out (or inspection and mainlenance a(ter ioosening lhumb screw? �Yes ❑ No <br />Is BWD locked inlo the p�per position and lhumb screv� lighlened? �'Yes ❑ No <br />Circle the BWD cov : irrigation cover liidscape area) I Irafiic load beariny cover (drive surtace) I access hatch (building) <br />Was property oivner shown Ihe IocalionAf tl��i�tmlled�BWD? �'Yes ❑ No Commenls: <br />Properly Owner s Sic <br />Installer's Signature: <br />Revision: 2 <br />Date: � `ZS ' � � <br />Date: �J � i� �.� <br />friday, September 12, 2014 <br />