Laserfiche WebLink
��✓ Ev�rr <br />INSTALLATION GHECKLIST <br />InsfallaGon Company N�me and Contact Info: <br />20�- <br />Dale Bac!���ater Prevenlion device (BWD) �vas insfall:.d: " q' ols Da�e ihis form vras completed: I�— I' �lS� <br />InstallaGon Property O�mer Name and Cont�ct Into: �rx1Jl � tto�ji� ��1�//ar �� ��g -���_ <br />—� _--, r I .L �T— <br />Property Address: <br />Pre•Ins+allaUon Inspection Checklist: <br />��� <br />Afl items must be checked 'Yes'!n order for a 8WD to be censidered for inst�flation <br />Is titere a basement or level of the iicuse that is at or near assumed sewer main elevaGon. [ � Yes ❑ h'o <br />4re there fi�ures in Uie house Iocaled below the upstream se�ver manhole rim elevaiion? [v� 1'es ❑�JNo <br />Is the side sewer currently UNPROTECTED from se�ver backups ldoes not have a BtND installed)? �✓J Yes ❑ i�o <br />Site Inspection Checklist: <br />Ail ifems must be cnecned'Yes'6efore inspecfion is considered .ompiefe <br />V��as side sewe: "N inspected irom building to sewer main? �Yes ❑ No Condition: <br />Does side sev�er have a: leasi 1°� slope irom [he building to sewer main7 [�Yes ❑ No Describe: .rx�� <br />Have all building sewer drzin connections to the side sev,er been itlenliiied and located? � Yes ❑ No <br />Have all properiy storm drain2ge connec(ions to the side sewer been idenGfed and iocated? I� Yes No <br />Hss property been evalu2ted for drairage deficiencies wilh finaings communi�ated io propery ovmer? �Yes ❑ F!o <br />Installation Details: � 1 _�I <br />`�Vhat type and 6rand of BWD ���as installed at fhis site Clean Che BWV, Grnder pu1mp, etc.): r�P��� <br />�Vhere a�as the devi�e instalied (general desoription, attach m2p)? �i yRrA /bt aJ� (S � <br />b�;as ?here any other sevier or storm drainage tvor'R completed in conjunction e�ith the BWD t�rork? Is so please tlescribe� Ni <br />Installation Checklist: ��% <br />Are a!I tlownspouts antl site d: ainage disconnected from upstream of th B�.^!D? �` Yes ❑ No Comments _ <br />Dces BWD posi!ioning meels minimum,,;lope requirement of >t %? �Yes ❑ Na C mments: �/�i � o <br />Can BWD be pulled out (or ins pection and maintenance after Ieosenin g humb screw? [�Yes ❑ No <br />is B�ND locked inlo the proper position and thumb screw tiyhtened? [� Yes [J No <br />Circle the 3WD cover: irrigaGon co�er lands� ap� I tra�c foa bearing eovar (drive surface) ! access hatch jb4ilding� <br />l^Jas properiy o�mershown lhe loca6on ot ihe mstalled BWD? �Yes ❑ No Comments: �.� 'S�__ <br />Property Owner's Signature: ( Du:a: ����—/ ��%/�� <br />Insl�llet's Signature: � 1 91�In �"o�..,</ Daie: ��" �`20��� <br />�7` <br />Revision: 2 1 Monday, Septem6er 15, 2074 <br />