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� <br />� <br />B/ACKIb�AT�R PREVENTION �EVICE FINAL <br />INSTALLATIOf� CHE�KLIST <br />Installalion Company Name and Contacl InFo: <br />Date Baokviater Prevenlion device (BWD) �vas inslalled: <br />Installafion Properly Owner Name and Contact Info: <br />Date this form was <br />PropertyAddress �0��� �'���(` �� <br />Pre-Installation Inspecfion Cheeklist: <br />All items musf be checked 'Yes' in order for a RWD to be considered (or installafion <br />Is there a basement or level of ihe house ihat is al or near assumed sewer main elc��atio�? �Yes ❑ No <br />Ara ihere Tixtures in the house loca(ed belo•�v fhe upstream se�ver manhole rim elevation? � c-]�yes ❑ No <br />�s the side sevrer currently UNPRO i �CTED fr�m sewer backups (does not have a BIND inslalletl�? �'es ❑ iJo <br />Site Inspection Cheeklist: <br />All items musf be checked 'Yes' 6efore inspectron is considered complete , <br />lNas side sewer TV inspectetl from building to se�ver main7 �'ft�s ❑ No Condition: : �� �-- L��y <br />Does side sewer have a:laast 14'o slope from ihe building to setiver main? [�'Yes ❑ No Describe: <br />Have all builtling sewer drain connections to Ihe side sewer been idenlified and located9 [�'fes ❑ No <br />Have all property storm tlrainage cenneclions to ihe side sewer been idenlified and localed7 [a'Pes ❑ IJo <br />Has property been evaluated (or drainage deficiencies with findings communicated lo property o�vner? [,�"es ❑ No <br />Installaticn Details: <br />What type antl brand o( BWD �vas installed at this site (Clean Chee{; BN'V, Grinderpump, etc.): ���N-!' �-���G <br />� <br />Where was ihe device instatled (general description, atlach map)7 ,�_ � CM-c)� ��- F'1.�^�— _ <br />Was there any olher sewer or slorm drainage vrork completed in conjunction with Ihe BWD work� Is so please describe: <br />Installation Checklist: <br />Are all tlownspouts and site drainage disconne�led fiom upsiream of lhe BWD? []' <br />Does BWD posilioning meels minimum slope requirement of %1 %? [�-YQs ❑ No <br />� ❑ No Commenis:�-' ��'�'Ls� <br />Comments: _ <br />Can BWD be pulletl out for inspection and maintenance aHer loosening thumb screw7 []�`HS ❑ No <br />Is BVJD locked into the proper posilio�n ',pd.lhu screw 6ghtened? []'rC�O No <br />Cirde ihe [iWD cover. irrigation coveY,rlandscape area � traffc load bearing cover (drive sur�ace) I access hatch (building) <br />`� ___.� <br />Was properly ovmer sho�.vn the I alion of Ihe installed BWD? --U�s ❑ No Comments: <br />Property Owners Signatyre: 't^-� Dzle: ��'�=1,�a�/ <br />Installer's Signature��_ Date: `� - `ti`�� 1� <br />i,evaion: 2 <br />7 <br />Friday, September 12, 2014 <br />, c �, .. � - � - ,�,.��� <br />�'iRxt$� � w ..a. .. . .. ..- ,. _ . -. <br />i�p,t..,- .. i 4' lQ".�'3:: s n . . , xAun,�t%�'�f�.�iYrXAi�Yi ,. . .ie„_. '`r^'y+6i�:i'y...�'t',' :.,.v.t '�barl:�:-`,3r.nx:� <br />