1121 GRAND AVE 2022-04-15 - Laserfiche WebLink

� ! �A�KWATER PREV�N'TIOfV D�VICE �INAL �, INSTALLATION CHECKLIST ; i Installation Compan��Name antl Contact Info: � ��-- � �� ? `�^-�•�^ � `�Z S " �'�S-�3 7 ' � Date Backv�aler Prevention device (BWD)vlas installetl� `-��"1 -l S Date lhis form was compteted: S - Co- �� i Inslailation Property Owner Name and Contast Info: � ��o�L C � �� o�-• �'`�� ' ��3 � - i Property Address: � �`�\ � �G c ��' `�``�� j Pre•Installation Inspection Checklist: � A�l items musi be checked'Yes'in order for a BWD to be considered for installafion � Is there a basement or level of the house that is at or near assumed sewer main elevalion? �Yes ❑ No ; Are there fi•dures in lhe house located belorr the upstream sev�er manhole rin elevation?[�Yes ❑No ' Is the side see�er currentl��UNPROTECTED from sewer backups (does not have a B'J�lD installed)?'�Yes ❑No • Site Inspection Checklist: ' AI(ifems must be cliecked'Yes'before inspection is considered complefe � VJas side seu�er TV inspec:ed from builtling to see+er main? 1�1i'Yes ❑ No Condition: ; Does side sevier have at least 1% slope(rom tne buiiding to sev;er main7 '�j Yes ❑ No Describe: ' Have all building sewer drain conneclions to Ihe side sewer been identified and located7 "�Yes ❑No ' Have all property storm drainage conneclions to the side seiver been identified antl located i �Yes ❑No ' Has property been evaluated fordrainage defciencies with findings communicaled to property o�vner? �Yes ❑ No Installation Details: 5�:,.* c�.:t�� ' UJhat type and brand ef BWD was installed at lhis sife(Ciean Check BWV, Grinder pump,etc.): `d�`� S�� ; i 17��here was Ihe device inslalletl (general tlescripfion, atlach map)� �US� ��e�� . INas there any otner sev:er or lorm ainage work o pleled in conjunclion v�ilh the BWD�vork� Is so pleas describe: _ � NO LkCt.' �� —oc- \ �� ^� L�t'Cti� � 'Lv�Sv.� �_ � o� Installation Checklist: , Are ail do�vnspouts and site drainage disconnected irom upstream of Ihe BWD? ❑Yes '[�No Comments: � Does BVJD posilioning meets minimum slope requirement of>1%7 0 Yes ❑ No Comments: Can 8WD be pulletl out for inspection and mainfenance a(ter loosening ihumb screw? �Yes ❑No � Is BWD locked info tne proper position and fhumb scree�tightened7 �Yes ❑fdo ______�_� � Circle ihe BVJD cover.irrigation cover(landscape area)/traffic loatl bearing cover(drive suriace) access hatch (buildin v • Was property owner shown Ihe location of Ihe installed BWD7 �Yes ❑ No Commenis: i Property O�vner's Signalure: Dale: ' Inslaller's Signature: �� Dale: S -[.,- 1� - i Revision:2 1 Friclay,September 12, 2014 !