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I�ACKlIVATER PREVENTION DEVICE FINA�. <br /> EY IIV�TALLATIOtV CHECKLIST' <br /> Inslailaiion Company Name and Contact In(o; � ,-� �' �.�,y - , <br /> Dale Backe�aler Prevenlion device(BVJD�c:as insialled���f 5� Date Ihi� form was compleled: .� 5 <br /> Installation Properiy Ovrrer Name and Contaci Inio: _��(� fl�t_ ��I D�(�(�/7 y'�� - �jp • '�3�� <br /> ProperyAddress 1G3I _ QQ � ��_��} rc�-2��� — <br /> Pre•Installation Inspection Checklist: <br /> All riems m��st be checked Yes'in order for a 8WD lo be considered foi insta!lation <br /> Is Ihere a basemani or level ol Ihe house ihal is al or near assumeo se�r+er main ete��ation? �[Cj Yes ❑ No <br /> Are ihere tixfures in lhe house located below lhe upslream se+uer manhole rim elevalion?0 Yes ❑ No <br /> Is Ihe side setiver currently UNPROTECTED irom sewer backups (does nol have a BWO inslall2d)? � Yes ❑ No <br /> Site Inspectlon Checklist: <br /> All ifems must be checked 'Yes'hefore inspeclion is crnsiaered compfete <br /> W2s side sewer TV inspected from building to setver main? 0 Yes ❑ Mo Condition; <br /> Does side sewer have ai least 1% slope from ihe building lo sewer main? �C] 1'es ❑�'o Describe: <br /> Have all building sewer drain conncclions to lhe side sewer been identified and located? (j]c Yes ❑ No <br /> Have all property storm drainaoe connechons to Ihe sida sewer been idenfifie�i and located? �] Yes ❑ No <br /> Has propeny bsen evaluafed tor drainage tleficiencies�viih findings communicaled fo property own2r^ �Yes ❑No <br /> Installation Details: <br /> What type and brand o(6bVD avas install2tl al tiiis sile (Clean Check 6VJV, Grinder pump,etc.): G�eGWt ChP('�. <br /> Where was ihe device installed(gen?ral description, alfach map)? OLl 1(�/. (r�,� <br /> Udas Ihere any other sewer or s�orm drainage work comple�ed in conjunction v�ith ihe BWD x�or'r,? Is so please descrihe <br /> Installation Checklist; <br /> Are all downspouis and site drainage disconnecled Irom upslream o;Ihe BWD? �j Yes ❑ No Commenls <br /> Docs BWD positioning meels minimum slope requiremen!of >t°�,? [�J Ycs �No Commenis: <br /> Can BWD be pulled out for inspeclion and mainlenance afler loosening Ihumb screw? � Yes [] No <br /> Is DWD locked inlo the proper positi -acllhumb screw tighlened? � Yes ❑ No <br /> Circle Ihe BIND cover: irrigalion c wer(landscape area)1 raf{ic load baaring cover (drive surfac�)/access hatr,h(building) <br /> Was property owner shown Ihe loca(ion of Ihe installed BWD? ,� Yes ❑ IJo Comments: <br /> �Property Owner's Sionature ��f.L_�_(r7i�j(� Dale: <br /> Ir�s�aller'sSign�lu��Gv. G��_�!-����_` _��3 � - --_� <br /> ---�- Date: <br /> RCvision: 2 1 Friday, September 12, 2014 <br />