3613 LOMBARD AVE 2022-05-02 - Laserfiche WebLink

� BACKWATER PREVENTION DEVICE FINAL INSTALLATION CHECKLIST InstallationCompanyNameandContactinfo: N�ao P(-.�Mt3�,.,4. LCC 2G(a -�}t�i(c -69Z% Date Backwater PrevenGon device (BWD) was installed: � I-1 O�- IQ- Date this form was completed: 11 � 1 Z- l y Installation Property Owner Name and Contacl Info: ��%FF la ��a-� S �'}2S ��•-� � 37 Property Address: ,� fa � 3 C-o.v� nVv+cn i�v u �v cvi�-rr �. P£ z�� Pre•Installation Inspectior Checklist: All items must be checked'Yes' in order /or a BWD to be considered for installation Is ihere a basement or level of the house that is at or near assumed sewer main elevation? [� Yes ❑ No h�e there fixtures in the house located below the upstream sewer manhole rim elevation? � Yes ❑ No I� t'ie side sewer currenlly UNPROTECTED from sewer backups (does not have a BWD installed)? (�.Yes ❑ No Site Inspection Checklist: All items must 6e checked'Yes' bafore rnspection is considered complele Was side sewer N inspected from building to sewer main? � Yes ❑ No CondiGon: C��o� Does side sewer have al leasi 1% slope irom the building to sewer main? �Yes ❑ No Desaibe: Have all building sewer dr2in connections to the side sevler been identified and located? `[�,Yes ❑ No Have all property stor,,: ,rainage connections to ihe side sewer been idenfified and located? � Yes ❑ No Has property been evaluafed for drainage deficiencies wilh flndings communicated to propeity owne� �Yes ❑ No lnstailation Details: What type ar�u brand oi BWD was installed at this site (Ciean Check BUW, Grinder pump, etc.): CLc�..� �i��`cle Where tvas lhe device installed (general description, attach map�? � L'"� Sr S'� 4 t- G.'- b�c��.a Was there any other sewer or storm drainage work completed in conjunction with tlie BWD work? Is so please describe: _ In>tallation Checklist: Are all dovmspouts and site drainage disconnected from upslream o( the BWD? �,Yes ❑ No Cornrnents: Does BWD posilioning meets minimum slope requirement of >1%1 � Yes ❑ No Comrtients: Can BWD be pulled oul for inspeclion and maintenance after loosening ihumb screw? � Yes ❑ No Is BWD locked inlo the proper position and thumb screw tightened? �-Yes ❑ No Circle the BIND cover: irrigation cover (landscape area) / Uaffic load bearing cover (drive surface)1 access hal�h (buildi�g) Was property owner shown :he location of the installed BWD? [� Yes ❑ No Comments: ProFerty Owner's SignaWre: �-�' ,��-,--- Date: l J / z— i �c installer's Signature: ._i !� _ Date: l� � �'�-" �9' Revision: 2 1 Tuesday, September 16, 2014 -