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�3ACl�UVA��R F�R�VEi��'li)iV D�'�iCE FIf�AL <br />lIVST'ALfl..A'�BO�Y CFiE�Kl.SS� <br />Installaiion Company Name and Contact Info: %� �e�� I��Hr� ���`+t y t.� �)= 7�p —�� G <br />Date Baclnvafer Prevention device (BWD) was installed: S—��5�"—il'� _ Date this iorm was completed� S—,2�'!.� <br />Installation Properly Owner Name and Coniact Info: S�� - ���. �'r}2., <br />Propsrty Address: <br />Pre•Installation Inspection Checklist: <br />All ilems must he checked'Yes' in order for a BbYD to 6e ,.onsidered for installation <br />Is there a basement or level oi the liouse lhat is at or near assumed se�ver mair elevation? �Yes ❑ No <br />Are there nxtures in the house localed below the ups(ream sev�er manhole rim elevation? [� Yes ❑ No <br />Is the side sewer currently UNPROTECTED �rom se�ver backups (does not liave a BWD installed)? [�f Yes ❑ No <br />Site Inspection Checklist: <br />All rlems musf be checked `Yes' belore inspectir,n is considered complete <br />14�as side sewer N inspected irom building lo sewer main? �71] Yes ❑ i�o Condition: T(�L 5 o�,.c �.'�J <br />Does side sewer have at least 1% slope from tho building to see�er maln7 (�Yes ❑ No Describe: <br />Have all hvilding sewer drain connections lo ihe side sev�er been identified and located? � Yes ❑ No <br />Have all pwperly storm drainaye conne�lions to the side sewer been iaentified and located? � Yes ❑ No <br />Flas property been evzluated for drainage deiiciencies wiih findings communicated to properly owne�l � Yes ❑ t��o <br />Installafion Details: <br />INhat type and brand of aWD ti:�as installed at this site lean Giie BWV, Grinder pump, etc.): <br />Wherr, was ihe deviCe Instalfed (general Bescription, afiach map)? �ra��}" �c-i L Na /d't. S,'?-�- <br />lNas ih��re any oiher sewer or storm drainaqe r;ork completed fn roi <br />� <br />InsfallaSion Checklisi: <br />wilh Ihe BWD v+ork? Is so please describe: _ <br />Aie oll down ,pouls and site draina�e disconnected irom upslream of the BN�D? �Yes ❑ tJo Commenis <br />Does 8WD posifioning meeis minimum slope requirement of >1°�? (�Yes ❑ ho Commenfs: <br />Can BWD he pulled oul for inspec6on and maintenance after loosening thumb screw? R(Yes ❑ No <br />Is BVJD locked into the proper posilion and thumb screvt G�hlenedl �Yes ❑ No <br />Circle the BWD cover. i gation.cnver �ndscape area) I traffic load bearing cover (drive surface)1 access halch (building) <br />lNas property o�.vner shovrn the locafion of the installed DNlD? [�Yes ❑ tdo <br />Property Ovmer's SignaWre: <br />Insiailers Signalure: ��� `�- � ___ <br />Commenls: . _ _ <br />Dale: <br />Date� S —?�� f S� <br />Revision: 2 1 Nonday, Seplember 15, "2014 <br />