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I <br /> � <br /> i <br /> �ACKiNATER PFt�VEN�'ION DEVIC� FINAL ; <br /> Q, INSTAL.LATION COiECKL.IST � <br /> ; <br /> � <br /> �'►�ri/cc�n �.��,� �� �r >��de �e��.��, ��� <br /> Installation Company�ame and Contact Info:3�CC I�i Cl' /-i J`�'�f-�%�5� �' '�'"1"�� ��� � ���� ' ��:� ; <br /> Date Back��aler Prevention device(BWD)was installed: 7 •� ' Date this form was completed:�=' /�___!�//^� i <br /> Instailation Property Owner Name and Contact info:������_l..���71.tJG`��C`�ll--- •`. <br /> i <br /> Property Address: ���t �t r�nti,:� f�J'�- _� Jp P �i�t�.�h� �lnU ->I�–� 7 33 i <br /> Pre-Installation Inspection Checklist: ; <br /> All ifems must be checked 'Yes'in ader for a Bl4�D to be considered for instalfafion � <br /> Is Ihere a basemenl or level ot ihe house that is al or near assumed sewer main elevation? �Yes ❑ No . <br /> Are there tixWres in the house located below Uie upslream sewer manhole rim elevation? [�1'es ❑Mo <br /> Is the side sewer currenUy UNPROTECTED irom sewer backups (does not have a BW�insialied)?�1'es ❑ No i <br /> Site Inspection Checklist: � <br /> A!!items must 6e checked'Yes'before inspecfion is considered complete ��� / � <br /> UJas side se�+�er TV inspecled Gom building lo sewer main? [��Yes ❑ No Condition: �_{}Lrl_ <br /> Does side sewer have al least 1%slope irom ihe builtling lo sevrer main? �'es ❑ No Describe: <br /> Flave all building sewer drain conneclions to Ihe side sev�er been identifietl and localed? �'Yes ❑No <br /> Flave ali property storm drainage conneelions to the side sewer been icenti5ed and localed? [�'Yes ❑ No ; <br /> Has properly been evaluated for drainage deticiencies v.�ith fintlings communicated to properly ov�ner? �Yes ❑No i <br /> Installation Details: D_ �1� '` �,' <br /> Whal rype and brand o(BWD was inslalled ai ihis sile (Clean Check RWV, Grinder pump, elc.): I�('��VL��,O�� ! <br /> Where was ihe device inslalled(general description, atiach map)? ��P I"Y �l(X.�,���r�T-S_�5.��L_ <br /> Was Uiere�ny olher seaver or slarm drainage vrork completed in co iunction with the �WD�vork? Is so please describe:_ ' <br /> ------ ------��nQ _. _ , <br /> Instailation Checklist: �i <br /> Are all downspoufs and site drainage tlisconnected trom upstream of the f3VJD? �Nes ❑No Commenis: , <br /> Does BWD positioning meels minimum slope requirement o(>1%? �Yes ❑ No Commenis_____ <br /> f;an EWD b��pulletl oui for inspeclion and mainlenance a(�er loosening thumh screw'! �Yes ❑No . <br /> Is BWD locked into the proper posilion and thumb screw tightened? ��Yes ❑ No . <br /> Cirde Ihe BWD wver. irriyalion cover I idscape area)I lraffic toad bearing r.over(drive sudace)!access hatch(building) i <br /> Was propeily owrer shown 6e location of Ihe inslalled BWD? (�Yes ❑ Ro Comments: ___ <br /> � � <br /> Properfy O�vner's Signaturef ,/1��_l�`/�v` �� . Date: _�– � �� �S <br /> 7/ <br /> Installer's Signalure:_✓ _�� —��_/' - _� Date:_ s� a-�.1�� <br /> Revision:2 1 �riday,Septemher 12, 201n • <br />