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i <br /> i <br /> �^ �-r•� BACi(WATER PREVENTIO(V DEVICE FINAL ' <br /> ���,-T iNSTALLATIOiV CHECKLIST � <br /> i <br /> �nc r�c�.�n �F� �� ^� S;de .�C�L�, 4 LG i <br /> Instailatian Company Name and Comact mfo::�,�C.F R� ���4a`s�"�q4�1���/�(���'►"1� �'4:�.���{� <br /> Oale Bac�waler Prevenlion device(BYJD)r�as instaited�c�1�I1,Oate Ihis fortn v�es comp'eted: a�J'(.� � <br /> Installalian Property Ownor Namn and Conlact Info��t}'-r'�f�'��T,�� pv'Yr.t iC_ �I��� - (,� '7G7t� � <br /> Properly Addrass:_]_�1 � �t �h��+ r Uf'(`P 1f �.AaL� � <br /> Pre•installation Inspection Chackl(st: i <br /> Afl ifems musf 6e checked'Yes'in artfer fo�a 8WD lo bo considered for installefi�n i <br /> Is thore a basement or Ievel of the house thal is a!or near assumed sewer main elaualion?(�Yes ❑No � <br /> Are Ihe�e fizfures in Ihe house located belaw ihe upslream sewer manhole rlm elevation?�Yes ❑No ; <br /> I <br /> Is Ihe sida sewer curcently UhpROTECTED from sen�er backups(dces not have a BWD instafled)7(�Yes ❑No � <br /> Site Inspection ChecklisL• ; <br /> i <br /> All ifems must 6e checked'Yes'6e�Ore inspect�on is considered complefe i <br /> vVas side sawer N inspecled from buflding to sewer main7 �Yes ❑No Condition: �-irn� i <br /> ooes side sewer na:��i��e���1%slope irom Ihe buiiding lo sev�er main? {�J Yes ❑No Describe: _ j <br /> Hava ail6uilding sewerdrain connec6ons to Ihe side se�ser been idenlified and iocated7 �Yes ❑No � <br /> Have all properly starm drainage cannections lo Ihe s!de sev:er been�denlfieci and Iccaled7 '�]Yes ❑No ° <br /> Has property Been evaluatetl for drainage defiaencies with findings comm�•iisated to property owner7 (�Yes ❑No � <br /> I <br /> installatinn Uelails: � <br /> Whai type and brand of 8WD was inslalled at Ihis sile(Clnan Check BVJV,Grinder"pu�mp,etc.):�pr''-�rY'� �n Q j <br /> NJhere was Ihe deui�e inslalted(geneml descripGon,attach map)? ,�N P C�x`F�r'�r' 0� �C Fi� t c I+ i <br /> i <br /> i <br /> Was ihera any olher se�ver or startn drainage work comp!elecf in conjur.clica wiih ihe 8WD�soik7 Is so piease doscnbe:_ i <br /> I��Y"t Q ' <br /> installatlon Checklist: ' <br /> Are all doNnspouls and s�le drainage disconnected from upstream of tha BWD7 Q Yes ❑No CommoNs: ; <br /> Does DIND posilioning meels minimum siope rCquimment of>1°07 (�Yes ❑No Commonls: � <br /> Can BWD be pulled oul for inspeclinn and mai�denan�e aflerloo5en�ng Ihumb sere�v9 �'J Yes ❑No I <br /> Is BWD Iccked inla 1he proper posiGnn and Ihumb saew lighlened? �Yes ❑�b ` <br /> Clrcle ihe Bl'uD co ec ini a1pn�er(�ndscape area)I lraffi�load bearing cover(drive sudark)1 access halch(buildmy) � <br /> 'J:as property awner sho�m tha locat n of the ins alled BWD? ❑Yes �h'o Commenls:lVnf C2Uci1 jo�I�P � <br /> Property O�vner's Signature: _ — Date: Z �/ /S`� <br /> InslailersSignature: % � S�� � `�' � Date: c� � <br /> Revision:2 �/ t Rlday,Seplem6cr 12,2014 � <br /> . i <br />