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i <br /> i <br /> �AC&�VAI'�R PR�1/�NTtOtV D�VICE FI{VAL. <br /> � <br /> Et�STAlLATIOBV CFIECKLIST ' <br /> i <br /> � <br /> � <br /> InstallafionCompanyNameandContactlnfo: M�� ���,����i ya� 7VU ��6� <br /> Date Baclnvater Prevention device(BWD)was installed: 'o�3-i S Dale ihis torm���as com�leted:�,-�3-I S� ' <br /> Installallon Property Ovmer Name and Contact Info: N ��c�" Srr�A1. ;��jG -1,� 1 S - � I��. �i <br /> Property Address:__�- �(�`� Co�h v �'� <br /> Pre•Installation Inspecfion Checkilst: <br /> All items mus!be checked'Ves'in order for a BIND fo be considered lor instailation <br /> is there a basement or level of the h�use lliat is at or near assumed sewer main elevation?(k]Yes ❑No <br /> Are there fixtures in Ihe house located below the upstream sewer manhole rim elevalion7�Yes ❑�do <br /> Is the sfde sew�er currently UNPFOTECTED from sevaer backups(does not ha��e a 8WD installed)?�Yes ❑No <br /> Site Inspection Checklist: � <br /> All items must be checked'Yes'beforo inspection(s consfdered corplete , <br /> Was side sewer N inspected from building to sewer main7 �Yes ❑No Condition, �a�G.�t(„��-�J1- � <br /> Ooes side se�ver have at least t%slope from the�uilding io se�ver main7 �Yes ❑No Descri6e: � <br /> Have all buiiding se�ver drain connacfions to the side sewer been idenlined and located? OX Yes ❑ No � <br /> Have all prope�storm drainage wnnec8ons to ihe side setver been Itlenti6etl ar�d locafed? �Yes ❑No <br /> lias property been evaluafed for drainage deficiencies wiih findings communicaled lo pre�etty owne�T �Yes ❑No � <br /> Instaliation Details: , <br /> UJhut type and Urand o(BVJD was inslalled at this site(Clean Check BWV,Grinder pump,etc.): C jv�r ��F�____ <br /> N�here was Il�e device inslalled(ganeral description,altach map)? h4�k ..c.�L __. <br /> Was there any olher sower or stortn drainac�e work completed in con]unclion v�Ni Ihe BWD work?Is so please doscribo:__ <br /> � <br /> Inslallalion Checldist: � <br /> Are all doti�nspouls and sife drainage disconnected from upstream of Ihe BIND? ❑Yes �No Comments: <br /> ooes BWD posltioning meet� minimum slope requiremont of>i%? (�Yes ❑No Comments: � <br /> Can BWD be pulled out for inspedion and moinienance after�oosening thumb screvJl �Yes ❑I�o ; <br /> Is BWD locked inln the propr.r pnsition and thumb screw tightened7 �Yes ❑No ; <br /> Cird�a th�RUW cover m lrs�ye landscape area)I iraific load bearing cover(drive suriace)1 access hatch(buliding) <br /> Was property owner shown Ihe focation of the Installed BWD7 �Yes ❑No CommaNs: � <br /> Proporty Owners Signature; Date: ; <br /> � i <br /> InsfallePs Signature;� � -V�J'L Date: �� � 2 3 IS <br /> Revi,ion:2 1 Mnnday,Septem6er 15,2014 <br />