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i <br /> ��C�V��'E�. �R�V�l�'TIOfV �E�/iC� Fel��AL <br /> � <br /> � 6NS1'ALLA,TI�h9 CFIE�KLIS�' ; <br /> . <br /> ; <br /> Installation Company tvame and Contact In(o:_M �z� I�l�n r���� +�y y � �= ]�p—�3(,c � <br /> Date Backv�ater Prevention de��ice (BWD)tit�as instalied: S'��'�� Dale this form veas completed: S-1 I - (IJ � <br /> Installation Property Owner Name and Contact Info: 2� c ��' � W ��e.��jG� y2r .�-S�� I?7� � <br /> Property Address: ���� U�-r-Z ��- <br /> Pre•Installation Inspection Checklist: ! <br /> AIf items must be checked 'Yes'in order for a BIND to be consldered for installation � <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?�Yes ❑ No � <br /> j <br /> Are there nxtures in the house located bsiow the upsiream se�ver manhole rim elevation?[]Yes ❑No � <br /> Is the side sewer currenlly UNPROTECTED from sev,�er i,�ckups (does no(have a BI��iD insialled)?[X�Yes ❑ No ! <br /> i <br /> Site Inspection Checklist: <br /> A!I r(ems must be checked'Yes'before rnspection is considered complete i <br /> INas side sewer TV inspected{rom building to sewer main? �Yes ❑No Condition: �`uu 1 _ f <br /> Does side se�a�er have at least 1°o siope from lhe building to sewer main? �1'ss ❑ No Descnbe: ! <br /> Have all building sew�er drain connections to the side se�t�er been identified and located? �Yes ❑ No ! <br /> Hdv2 all property storm drainage connections to the side sewer been identined and localed? f�Yes ❑ No ! <br /> Has property been evafuated for drainage dericiencies vrith findings communicated to property ewne�? [�j 1'es ❑ �'o � <br /> Instaliation Details: � <br /> INhat type and hrand of BWD was installetl at this sile(Ciean Check BWV, Grinder purnp,etc.): C`^2�'!�S j <br /> i <br /> Wherre�aas lhe1�device insGtalled(general description, aflach map)? f.c,w��_M �IJ�� d- Fl��1 Cywz � 1 <br /> --GG �ro.iT.�w aJ �a �n'/'S --� i <br /> i <br /> � <br /> lNas there any other sewer or storm drainage�tirork completed in conjunction wilh the BWD v�ork? Is so please describe: ; <br /> �I� i <br /> i <br /> Installation Checklist: � <br /> Are all dov;nspouls and sile drainage disconnected from upsiream of the BWD'? �j Yes ❑ No Comments: ; <br /> i <br /> �oes BWD positioning meets minimum slope requirr.ment of>1%1 �Yes ❑No Commenis: � <br /> Can BWD be pulled oui far inspection and maintenance aker loosening thumb scre�v? � Yes ❑No j <br /> Is BWD locked into the proper position and fhumb screw tightened7 ❑Yes ❑ No ; <br /> Circ!e lhe BVJD cover. irrigation cover(landscape area)i traHic load bearing cover(drive surface I access hafch l�ilding) � <br /> 1Nas property o�vner shown the location of lhe ins(alletl BWD? �Yes ❑tJo Commenis: � <br /> i <br /> Property Owner's 5igna�ure: Data� � <br /> Ins(aller's Signalure: ���,� Date: S—L( —1 ,� � <br /> i <br /> Revision:2 1 Ivlonday,September 15,2014 i <br />