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� <br /> I <br /> BACKWATER PREVENTION DEVICE FINAL � <br /> ItvSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: � !�J r u��i�, .� �ci ' <br /> Dale Ba�k�a�ater Proveniion device (84VD)�eas insizlled: �SI(zl�s Date this form�,�as compieted: $��Z//S � <br /> Installation Properly O�rner Name and Contact Info: <br /> Proper�}rAddress: �3Z6 �i�tS-1r:�{- Cvu�.tt, rvA 9SSZ01 � <br /> Pre-installation Inspection Checklist: <br /> Afl it�n�s must be cfrecked 'Yes'in order(er a BNID to be considerea lor installafion <br /> , <br /> is there a basemenl or tevel of t'ne hcuse tnat is at cr near assumed selver main elevation?�Yes ❑ \o : <br /> Are there fixtures in the hcuse located belo�v the upstream sewer manhole rim elevation? �Yes ❑ No <br /> Is the side seti��er currently UNPROTECTED fwm se�ver ba�kups(dozs not have a B!ND ins:allatl}?�Yes ❑ �o ; <br /> Site Inspection Checklfst: , <br /> Alf items must h,e checked'Yes'6e%re inspection rs cor,siaerad complete <br /> Vlas side sew�r N inspzcted froT� buildina to ser:er m2in? ;�Yes ❑ No Condition:�-eas�eo �o.,dsl,'on <br /> Dces sida sev�er have at 12ast 1°o s'ope frcm the bui!ding to se�r�er main7 �Yes ❑ i�7o Describe: <br /> Ha��e oll bulltl ng setiver drain connections to the side set�;er baan identified and located? �Yes ❑ No <br /> rave all procerty sterm drainage connections to the side sesver been identiiied and located'? �]Yes ❑ �o , <br /> Nas oroperty oeen evaluated for draina�e defici2ncies v;ith �ndirgs communicated to property c��:ner? � Yes ❑ No <br /> Installation Details: <br /> V�haf type and brand oi BIVD r;as installed at!his sit2 (Clean Check 3,!�V, Grinder pump, etc.)� s .N ,� a wV <br /> V;�herz v�as ihe device mslallzd(general description,attach m2p}7 ���MJk�J S�ee;�-�ro������.uu � , <br /> (G1G�C!_�rl'�r��adS^+vr/ �+ro�ql�f�a Ss/�ace <br /> Vlas Ihere any otner sewer or stortn dra! ae work completed in conjunction tivilh the 84VD ercrk? Is so Fleas� deecribe� _ <br /> ��� <br /> Installation Checklish <br /> P,r�all doe;nsoouts and site drainage disconne�ted frem upstream or the BWD? ,�1'es ❑ No Comments: __ <br /> Dxs BWD positioning meets minimum slope requiremeni of>19;? �Yes �� Ao Comments: <br /> Can 6V�'D be pulled oui for inspection and maintenance after loosening lhumb scre�v? �Yes ❑ No <br /> Is BVUD locked into the proper position and thumb screw ti?htened? �'Yes ❑ No i <br /> Circle the BNlD cover. irrigation co��er(landscape area)1 lrafnc load bearing cover(drive suriace)I access hatch (building) <br /> lh�as property ovmer shoe:n the location of the instailed Bl^!D? �{I Yes ❑No Comments: i <br /> Property Owner's Signafure: Daie: � <br /> / ; <br /> Installers 5ignature Date: �/�li�f <br /> itevisi�,,: � _ �4ondap, September 75, 2�14 <br /> �� <br />