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' . Ii <br /> � BACKWATER PREVENTION DEVICE FINNL <br /> EY �� INSTALLATION CHECKLIST <br /> � I <br /> In<<a!�at�ur, Company Iv�arie ard Ccnla:( In(o:`-.,Q rvl �/'�r1_L.�� �L i,1�i �( � C , <br /> Date Back�;�ater Prevenbon device (BY��G)ti�as installed: 3 z5 i 5';` Date t�iis torm e�as complete�l � `� I �5 <br /> I �staltafion PropeAy C�+ner Name and Contact Info: _�o�� L��,��� ti15 - 3c,�.�. _ i�_ _ <br /> froperiyHadress 21 �q �`�.e gj�e,� ��.. �.� ,�.,1�}- (N 9Fczc� <br /> �- - `� �----L --- -- <br /> Pra•Inslallation Inspection Checklist: i <br /> ;i,ite;ns must be checked 'Yes'in order for a Bl4�D to be consioered lor�installaUon. <br /> �s chere a basement or le��el of ihe house thal is zt or near assumed szviar main eleti�aGon? ;��es ❑ p:o <br /> A�e !nere fixtures in lhe house localed belov;the upstream sev:er manhtile rim efevation?[✓� Yes ❑�N <br /> Is 'he side se��-er r,urrently UNPROTECTED from se�ver hackups (docs no; f•�av� a 31��D m:fa�'�ed)� �✓Ye> ❑ Xv <br /> Site Inspection Checklist: <br /> ;i�'i;ems m�fsf C� :necked Yes'be`ore inspection is considered coiT�pfete <br /> l�as side se�ve;r TV mspecte� frotn b�dding to see�er main? �Yes [] No Condit on: <br /> D��s side sewer t�ave al leasl 1°o slope(rom the builtling to sewer main7 [�Yes (_� h�o D>scr�6e <br /> ii�v� all bulding sevrer drain r.ennections to the side sewer been �tlenlified and ioczted? �Yes ❑No <br /> ii;.�va all propei�y;,torm ciiainace conneclions to thr, sid�see✓er heen ia;;utifed and io�aled7 ��es ❑ No <br /> !'3s cropertq t;F:en evaluated tor drainage defciencies�vith 5ndings communicated fo prcperly owner� [�Yes [; N; <br /> Installation Details: i <br /> ':Vhal rype and hrand oi E314��was inslalled al this site (Clean Check BLNV, Grinder pump, elc.):�(ui�, C��k <br /> � <br /> �Primre i�;as Ihe device instal ed �general description, attach map)? �� �asy{�par ..�-{,� S{-��s lea�,(,..� <br /> �dzc� <br /> --`— -- - <br /> � i <br /> '.'cas tl�ere any oth��r sewer or stonn drainaye work compleled in conjunction �vilh Ihe E3N�D c;ork? Is so pleaso de,cnLe /JC <br /> � <br /> ----- — � <br /> Installation Checl;list: <br /> ;',:�� �ill dov;nspouf� and site drainage disconne�led from upsUeam of lhe�WD? � es ( 1 No Cann,enfs _ <br /> Uce� G4VD posilioning meets rninimum slopc requiremenl of>14'0? ❑ Yes ❑ No Comm�rnfy <br /> Can BWU be pulled oul(or inspection and mainlenance afler loosen�ng IHwnb screv+? ��; Yes j ; tJo <br /> Is E1VdU locked into the proper pasition and thumU scre�v iightened'? �s ❑ Nn <br /> Cnr,!e the BVJD cover_ irrigation cover(landscape area)1 iratfic load bearing cover(drwe surface) i acco;s na;ch (build�n�) <br /> 1`aas property owner shown the location of fhe inslalled BN1D? [].Y�5 �] No CommeNs: _ _ <br /> P�iipe�y 0wner's Signalure:---� �.f_!�_a_L.==—_ Dafe�_��� /_Z O/1 �-- <br /> � -/ — -___. <br /> Ins�aller's SignalurF �� w� __-�. �,..n�c-�. -- ,--- Date: �/�I 5 _ <br /> � i -- --__ <br /> r,,,�,<,ru ? � i�trnday, Septc�inLer 15, ?014 <br />