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I <br /> i <br /> BR��KW/�TE(� PRE\t'Ef�1TIQN DEVIC� :�icJAL <br /> � <br /> , INSTALLl�7lON CHECKLI�T � <br /> i <br /> i <br /> i <br /> Installalion Company Name and Confacl info: /��o/�li l�/!���i?���� � <br /> Date BacMvater Prevenlion device(BWD)was installed: z �/fl//� Date this form was completed: �f�3%i� � <br /> i <br /> Installation Propery O��Ter Name and Contaci Infa l � r�� �c��� �r. � <br /> PropertyAddress: � �/,� Cdd�`i i <br /> Pre•Installation Inspection Checklist: � <br /> AA items must he checked'Yes'in order for e BVJD to be considered tor installation �/ <br /> Is there a basement or level of the house that is at or near assumed see+er main elevalion7[a Yes ❑No <br /> !va there ixtures in ihe house located b:low the upstream sewer manhole rim eleea,ion?�Yes ❑IJo ; <br /> Is the side sev:er currenUy UNPRO7ECTED irom see�er backups(does not have a BVVD installed)7[�'1'es ❑ho ; <br /> 5ite Inspestion Checkllst: <br /> All r(ems must be checked'Yes'before inspection is considered comp'ete � <br /> INas side se���er N inspecled from building io se�t�er main? [�es ❑ No Contlition: ; <br /> Does side se�a�er have at least 1%slope from Ihe bui�ding to sewer main7 �es ❑Ro Describe: <br /> Have all building se��;er drain connections to the side sew�er been idenl�ied nd located? [�.Yes ❑No <br /> Ha�re zll prope�ty storm drainage connections to the side sevrer been itlentifiad and located7 s ❑ No ' <br /> Has prcperty been evaivated for drainage deGciencies�•.�Ih fndings communicaled;o propert ovrner7 ' Yes ❑ No � <br /> Installation Details: � <br /> 11'hat type and brand of BI�'D�aas installed at this sit Clea �inder pump,etc.): � <br /> VJhere�vas tne device inslalled(yeneral description,at a ,�.ck Prr✓F � <br /> i <br /> l4�as lhere any other see+er or slorm drainage���ork complsted in conjunction with ihe BI�VD���ork?Is so please describe:_ ! <br /> nrv ; <br /> i <br /> Inslallalion Checklist: i <br /> Are all do�vnspouts and site drainage disconnected from upstream of the BWD7 Yes ❑No Comments: <br /> Does BWD positioning meets minimum slope requiremenl oi>1%9 �Yes No Commenls: � <br /> Can DWD be pulled out tor inspeclion and maintenance after loosening lhumb screva? �J Yes ❑ No <br /> Is BWD locked Inlo Ihe proper posillon and thumb scre�v tightened? �Yes ❑No� I <br /> Circle the BI�uD cever: irrigaUon cover(landseape area) ic oad bearing co� _iyesu ace-- ccess hatch(building) � <br /> lNas property owner shown lhe localion of the installed BWD? (�es ❑No Comments: <br /> i <br /> Property Oe�ners Signa Date: 3/��S/�f i <br /> Installers Slgnatur . � _�_ - Date: �/ill/i� � <br /> Revision: 2 ] Friday,Septemher 12,2014 I <br /> I <br /> I <br />