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! <br /> � <br /> � <br /> t <br /> BACKV►,�A�fER PREVENTION DEVICE FINAL � <br /> a INSTALLATION CHECI�LIST i <br /> � <br /> �j � � f / � <br /> Inslallalion Company Name and Contact Info���,, �� 1+�"� �'� � � .C�� ` <br /> Dale Backtivaler Prevention device(BWD)was installed r" �for�n was completed: � �;-l� � <br /> Inslal!ation Prooe�y O:m�r IJame and Conlact Info: � �S ; <br /> Property Atldress: ,� .Sd L 1"11,a �'�, �tu.�c`.�`t'F 4/�4' ��� i � <br /> i <br /> Pre-Installation Inspzction Check i�i: ' <br /> All items musl be check.ed'Yes'in order lor a BV✓D to be considered Iorinstallatia+ <br /> Is there a basement or level oi the house Ihat is at or near assumed sewer main elevation7 Yes ❑ No � <br /> Nre ihere fxlures in the house Iocated `�elo�e the upslream se�ver msnhole rim elevation7�es ❑ No ; <br /> Is the side se�ver currentiy U�'?ROTEC i ED from se�ver backups(does not have a BWD i�stalled)? I7I Yes ❑No t <br /> Site Inspection Checklist: J � <br /> , <br /> Al!items must be checked'Yes'6e/ore inspecr�on�s considered c mplele � <br /> Was side sewer TV inspected(rom builtling to sec;er man? �Yes ❑No Condilion � <br /> 1 <br /> Does side see�er have at least 1%slope from Ihe t.uildine ?o sev�er main? �Yes ❑ N,o_,t,Describe: � <br /> Have all be�lding sev�er dr2in canne�tions to Ihe aide se+�er been identi6ed and Iocaled? V I Yes ❑ �o � <br /> ! ; <br /> Have ali properiy storm drainage connections to�he side sewer 6een idenlified and located? �Yes ❑No ; <br /> Has properly been evai,iated`or drainage deficienues«�ith findmgs communicated to property ov+ner7 �Yes ❑No ! <br /> Installation Details: � ' I <br /> �Vha;type and brand of BVJD a�as installed at lhis site(Clean Check BWV, Grinder pump, et � - � <br /> t4�here�eas lhe device installed(generai descripticn, attach map)? �y�� • ! <br /> , <br /> — ! <br /> Was there any other se�ver or storm drainaga��atk�ompleted in conjunction wilh the B4VD work7 Is so please descnbe: _ ; <br /> ��C i � <br /> Installation Checklish � � <br /> � I <br /> Are all doivnspouts and sile drainage disconnected fiom upstream of Ihe BV�D�Yes ❑No Commenls: i <br /> Does BWD posilioning meets minimum slope requirement of>1%? �Yes No Comments: _ ; <br /> Can 814'D be pulled out(or inspection and mainlenance a(ter loos^_ning ihumb screw? � Yes ❑No ! <br /> Is BWD locked inro lhe proper position and thmnb scre�v tighlened'1 �]Yes ❑No ; <br /> Circle Ihe BWD cover.irrigation cover(landscape area)/traffic load bearing cover(drive suriace)/access hatch(buitding) ' <br /> Was property owner shown the location of;he installed�WD? �Yes ❑ No Comments: � <br /> 1 /� `-- ; <br /> Prope�ty Owner's Signature: �tiY�.c� `z��-�- te: �' V� '� �� 1 <br /> Inslaller's Signature: ✓t�-- Date: ,���-- �� � <br /> � j <br /> Rev¢ion: 7 � 1 Friday,Septem�er 12, 2014 � <br /> ; <br /> � <br />