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i <br /> � <br /> BA�:l�W/�T�F� F�R�VER9TlON DEVICE FINAI_ . <br /> �, BN5TALLATIO�J CHECKLIST � � <br /> � <br /> ; <br /> � <br /> � <br /> Inslallalion Company �ame and Con(act Inio: i <br /> Date Backevater Prevenlion device(BWD)vaas installed: Date this form was completed: � <br /> I <br /> InstallaGon Prop�rt��O�vner Name and Con(acl Info: �rz��-r c ,�S,:N �,��� r�•+ ye•-t�. _ � <br /> ProperlyAddress: fz�,z ������,=� �✓c����c _ � <br /> t <br /> Pre-Installation Inspection Checkiist: i <br /> Nfl items must be checked'Yes'in order!or a B�I�D to be considered for installation ; <br /> Is them a basement or level ot the house ihat is at or near assumed sewer main elevalion?�/ Yes ❑ No I <br /> Are Ihere fixlures in the house located belo�v the upslream sewer manhole rim elevalion?Q Yes ❑ No � <br /> Is the side sewer currently UNPROTECTED irom sevaer backups(does not have a BWD inslalled)? /❑Yes ❑ No ! <br /> i <br /> Site Inspection Checklist: , <br /> AIf ifents musi be checked'Yes'6e�ore inspecfion is considered compfete ��,� _ �;, „��,,,�,...y-�.� � <br /> Was side sea�er TV inspected from building to set�;er main? �Yes ❑ No Condition: b�u: J�S.,�,= e:_v,�� _ � <br /> Does side sev��er have al leasl 1%siope irom the building to sewer main? ❑Yes 0 No Describe: �+o�.o..,+..�n:ev <br /> Have all building sewer drain conneclions lo lhe side sewer becn identifed and located? �Yes ❑ �o <br /> Have all property storm drainage connections to�he side see�er been identified and located? [/]Yes ❑ No <br /> I las property been ev2ivated for drainage deficiencies with findings communieated to property ovrner? �Yes ❑No <br /> � <br /> Installatimi�etails; : <br /> 1^,'hal typr. and brand of 81ND�vas inslalled at this site Ciean Chec UVV, Grinder pump,eic.): ; <br /> Where was the device installed(general descriplinn, atta�h map)? __ j <br /> � <br /> i <br /> Was ihere any lher$evaeror slorm drainagne�vodc completed in conjunction wilh ihe BWD�vork?Is so please desr.nhe:_ ! <br /> n/ir( �4/AcF�NeNi -f-o _"E.^�r.�C ��.n,�< ���-19.� , ,., ����< 5<wef� i <br /> Installation ChecklisL• <br /> Arc all doivnspouls and site drainage dis�onnr.ded(rom upstream of the(3WD? �j Yes [� No Commr.nts <br /> Uocs BWD positioning meets minimum slope requirement oh1%? �Yes ❑ No Camments <br /> Can [3WD be pulled oul for inspection and maintenanr,e afler looseniny thumb scre�v? �Yes ❑ No <br /> Is BN�D lockr.d inlo the proper position and thumb screv�lighlened? ❑Yr.s ❑No <br /> Cirr,le Ihe BIND cover:irrigalion cover(landscape area)/iraffic load bearing cover(drive sur(ace)!access hatch(hwiding) <br /> Was propr.ily o���ner shov,m the locafion o(ihe in�lalled BV��D? �J Yes ❑ No Comments: <br /> Property Owncr's Signature: __ Date:__ _,_ ' <br /> i <br /> � <br /> Installcr's Signaturr.:__ �<���" __ __ � <br /> Revision� J 1 Friday,Sepleinber 12, 2014 <br /> i <br />