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� <br /> � <br /> � <br /> { <br /> ���C��iie4T�R Pi2��91�t��'�Oi� ��1/IG� FIYVAL <br /> d Il��T�1LLA7°RO� ����&CE.IST <br /> � <br /> ; <br /> insfallalion Company Name and Contact Info: M ue� I�1 ti�����'��/ 4 � S- 7�U��'3G c � <br /> I <br /> Dafe Backtvaler PrevenGon device(BWD)was installed: �'1-� 1-I 5 pate ihis torm tvas completed� `� � I'f- 1 � � <br /> i <br /> installation Properiy Owner Name and Contact Info: �<�.+-• I�c,� 1 c I 3�v � � 76 � �y y i <br /> Property Nddress: y y �(� �o I l�y (,}t� � <br /> pre•Installation Inspection Checklist: � <br /> .41f ifems musf be checked'Yes'in order lor a BV✓D to be considercd forinslallatiun � <br /> Is there a basement or level of Ihe house that is al or near assumed sewer main elevation7�Yes ❑ No i <br /> Are there fixtures(n the house located below the upstream sewer manhole rim elevation?�Yes ❑ No <br /> Is tlie side sevaer currently UNPROTECTED from sew�er backups (does not liave a BWD inslalled)?�Yes ❑ No � <br /> Site Inspection Checklist; <br /> I <br /> All items must be checked'Yes'6efore inspection is considered complete ; <br /> Sns�.�c d:/�r <br /> bUas slde se�ver N inspected from building lo se�l�er main? �Yes ❑A'o Condition: C o�c�� <br /> Does side sewer have at least 1%slope from the building to se�ver main? �Yes ❑No Describe: <br /> i <br /> Have ail building sewer drain connections to the side sewer been identified and located? (�(Yes ❑ No � <br /> Nave all property storrn drainage connections to lhe side sewer been identified and located? �Yes ❑No ! <br /> Has property been evaluated tor drainage deficiencies�vilh findings c�mmunicaled to property o�vnerl �Yes ❑No � <br /> Instailation Details: � <br /> What type and brantl of�WD was inslalled al this site(Clean Check BWV,Grinder pump,elcJ: L�ec-,. c 1..� c1c I <br /> Where was lhe device instatied general descriplion,atls�h map)? �ri`�C.- �i �-.�}c...� � <br /> r,,`�{-'� ( � —� i <br /> 0 , <br /> Was there any oiher sewer or storm draina�o v;ork completed in conjunction with Ihe BWD kork? is so please descri�e: � <br /> N'//f- — I <br /> � <br /> Insiallation Checklist: i <br /> i <br /> Are all do�vnspouts and site drainage disconnected from upstream of Ihe BWD? �s Yes ❑ No Commenls: � <br /> Does BWD positioning meets minimum slope requirement of>t%7 j�Yes ❑No Comments: j <br /> Can B1ND 6e pulled out for inspection antl maintenance after loosening ihumb screw? �Yes ❑No ; <br /> Is BN�D locked into the proper position and thumb screva tightened? Yes ❑ No i <br /> Circle ihe BWD cover: imgation cover(landscape area)/ a_fi�Joad bearing c�� drive sudace}/access halch(builtling) ! <br /> Was property owner shown lhe location of Ihe inslalled BWD? �Yes ❑ No Comments: � <br /> � <br /> � <br /> Property Ovaner's Signalure: Date: � <br /> (nstalle�'s Signafure: GL=� : / �t-'"e-- bate: ��—! 7 - � S ; <br /> I <br /> Revision: 2 1 Monday,September 15,2014 ! <br /> i <br />