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�ACK1lVATEf� PREVE{�TION DE1010E F!l�A� ' <br /> Q, INSTALLAl'iQf� CI�ECKLiST' <br /> �ru,�r�c�xn ��-;p �� � �,de Se;.L�,f, L LG i <br /> Installation Company Name and Contact Info:.1��C.e�' [• u,Z;)�,v�-L��,Y��('i rrl� ��"�i�;Z'��iC� ���;� � <br /> Date Backvaater Prevention device(BV��D)was installed:���:�.���Date Ih�is iorm�,�as completed:-y� i <br /> InstallationPropedy0w�erNameandCcntacllnfo: l:l;lV�� �1�� � � _�- �,7- �?�Z� <br /> =ro � Address: �� t� ,�. 1L' liV� Y2 � �'Tl ���.��J � <br /> P��'Y <br /> Pre•Instaliation Inspection Checklist: � <br /> All items must 6e checked'Ves'in order fa a 8V✓D to be considered for instailalion i <br /> Is there a basement or level of the house lhal is at or near assumed sewer main elevation? �es ❑ No � <br /> Hre there tixlures in the house locafed below ihe upslream sewer manhole rim etevation?j�Yes �No i <br /> Is the side se�ver currently UNPROTECTED from sev�er backups(does not have a BWD installed)?�'Yes ❑ No ; <br /> 5ite Inspection Checklist: i <br /> A�I rtems must 6e checked'Yes'before inspeclron is considered complete � <br /> IVas side sevrer TV inspecled from buildingdo se���er main? �Yes ❑No Cond�Gon: �� i <br /> Does side sewer have al least 1%slope from the building to sewer main? '�Yes ❑No Descnbe: ; <br /> Have all building sev�er drain corneGlons to Ihe side sewer been identi(ied and located? .�Yes ❑No j <br /> Have all properiy seorm drainage connections to the side sewer been identified and Iccated? ,(�Yes ❑ No � <br /> Has propzrty been evalualed for drainage deficiencies with findings communicated lo property ov:ner? �Yes ❑ No ; <br /> Installation Details: � <br /> l�Uhat type and brand of BWD tivas installed at Ihis site(Clean Check BVJV, Grinder pum��p�,etc.)��EC-�]'"�.�-I i <br /> 1�1�here was 1he device inslalled(general description,aUach map)7 ��._[��'_�S.�E:S��_{�S-�L1� ; <br /> � <br /> •- i <br /> 'A�as there any other sewer or storm drainage�:ork completed in c*on�'u_nc_lio'n with Ihe 6WD�vork7 Is so p�ease describe:_ � <br /> 1`l�Y�.� i <br /> Instailation Checklist: { <br /> ;ire all dovmspouls and sile drainage disconnected from upstream of ihe[�W07 �Yes ❑No Commenls: ; <br /> Daes BWD posilioning meets minimum slope requirement of>1°/,7 �Yes ❑No Comments:_ i <br /> Can BWD be pulled out(or inspeclion and maintenance after loosening lhumb screw? [�Yes ❑No i <br /> Is f3WD locked into the proper posilion and thumb scre�o tighlened? [�Yes ❑No � <br /> Circle the BVJD cov . irrigation cov �(landscape area)11raKc load bearing cover(drive surtace)I access hatch (building) i <br /> 14�as property owner shotivn the loeation oi Ihe installed BWD? �Yes ❑ No Comments: ! <br /> \ � /7. � <br /> Property Owner's Signalure: �� � ���1 Date: I� � I <br /> � - l - i <br /> instailers Signalu r--- �� • Date: ' <br /> � <br /> Revision:2 1 Friday, Septemher 12, 2014 � <br /> i <br />