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' C�A�KWA'fFFi PREVEhTI�JN D�VICE Fl�AL <br /> � T fl�STALLA�'InN CHECKLIST <br /> 0 <br /> Installatlon Company Name antl Contacf !nlo:� ;��,r�/(�r,r,;� _ <br /> Dafe Back�valer Prevenlion device (t3N±D):;-as installed: I � Z�i �j�Dale lhis form was compleled: � Z �J <br /> Insfallation Froperfy O,vner Name and Conlact Info: � On � �-�o �' 1 ' �':IY-�% Y�I j <br /> PropertyAcidress: �r(/ � �.,�/-� "1 _ G __ <br /> Pre•Instaliation Inspection Checklis� . <br /> liil items musl be checked 'Yes'in ord�r lor a t3lh�D to be considered lor i, �!ior <br /> is Ihere a basement or level of Ihe house ihal I; at or near assumed se�ver main elevalion? [ 'I Yes ❑ �do <br /> P.re there fixtures in ihe hcusz locatec balow the upsUeam se�,�aer manho!e rim ei2vation?�f Yes ❑ fJo <br /> Is fhe side s�wer currenily UtJPROTECTED irom se;var bac�ups (does not h2vo 2 BWD insfalled)?�1'es ❑ �do <br /> Site Inspection Checkllst: <br /> Ali items must be checked 'Yrs'belore lnspection!s cons�dered comple(e <br /> !�'!as slde sewer TV Inspectetl from buildirg to see�er,Tain? �Yes ❑N� Condifion:_ __ <br /> Doos sitle sev:er have at leasl t°�6 slope from the buiiding to seti^;er mair? �Yes ❑ No Describz:^ <br /> Have all builtling sewer drain connecticns to the side sFe�er been idenfiGad and!ocated� [�Cl'es ❑ Nn <br /> Have all property siorm drainage conneclions to Ihe side sewer been Itlentified and located7 [�Yes ❑ Mo <br /> Has proeerty been e�ialuafed for dreinage deficiencles tivith lindings communicated to properiy ovmer? �] Yes ❑ ho <br /> Installation Detoils: <br /> !Nhal type and brand of BWD eias installed at lhis site(Clean Check B' Grin,d�e�r'�p�um,p�,elc.):C�{�{�''�,� ./� <br /> bl�nere v�as U�e devir.a iitslaiied(general descripl�on, attach map)? _�� =��a,�l�it,r . 1�;f�uL� � _. <br /> Vdas�he�� any other sevrer or sform drainage work completed i�clion t��ilh ihe BVti'D work7 Is so please desaibe:_ <br /> Installr,'ion Checklist: <br /> Are all dc,vnspnuls and sl(o dralnage disr.onnecled from upstream of!he DWD? (�Yes ❑ Nfl Commen's:____ <br /> Does BWD posilloning meels minimum slope requirement of>1°�o9 [�,'�'es ❑No Cemmonts:, __ <br /> Can BWD be pulled out for inspecllon and malntenanca afir.r loosening ihumb scre�v7 �Yes ❑No <br /> Is B�VD locked into !ho preper posi(iorygnd thumb screvi lighlened? �Yes ❑No <br /> Cirde tho B'ND cover. irr�gali cover(landsc�pe a )/Va((ic ioad bsaring cover(drive surface)12ccess hatch(Lullding) <br /> 4Vas property o�vner shon�n ihe locallo� of t���talle 'N ? �Yes [� No Commen�s: __ <br /> Proporty0evner'sSianatur :,.Y _ Dale / �7 /5� _ <br /> Inslalfer's Signature: �? � �' ' Dalo: � l�/�-� <br /> - -L-- —— <br /> Revslon: 2 1 Frlday, ;eptamber 1J, 2014 <br />