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�/ BACKWATER P'RE ENTlOf� DEVICt FINAL <br /> ��lA� INSTQL�A. ,ON �HECKLIS� <br /> �J_. . <br /> ' `t� <br /> I _ 'y � . � : '�l <br /> Instatlation Comp2ny I�'ame and Contad Info: /,-?,�"�,r' ; I C . l `'• i'' �; -'r -,;�� : "`, '�' ���.- _ _ _ . <br /> Daie Back�'+aler P�evenuon devlcc(BVVD)�vas inslailetl: � � 1��ate this form vrzs completed �[:�1� <br /> Installation Property O:vn^r�lame and Contacl Info p� ' ��'Y.1 �7� �?_=��-�1�,1��— <br /> PropertyAddress 1('I (���['_�-t'�,i^ l;�, i ��)t',(.�� L���.ac^, � _ --- <br /> Pre•Installatian Inspection ChecklisC I <br /> All dems musl 6e thecGe,i'Yes'm order for a BWD to bE LD^ � ereC/nr m;tal!afion <br /> Is lhere a basemenl cr I?vef of ine ho��s=lhzl is at or near as � med se�ser main e!e��(�cn7�,J Yes ❑ No <br /> Are lhere f�xlures m tha house loc.(ed below lhe upstream s :r manhole nm elevauon���Yss ❑f:'e <br /> Is the sid?se�:�er currently UNPROTEC7ED frem sewzr u2c � s(does nct have a Bl'JD�nstalled)��1'es ❑ �10 <br /> Site Insoection Checkiist: i <br /> Ai!,fems must oa cneclied'Yes'berore inspectiai is censide compiete <br /> lNas side sev+er TV mspected frem buildmg to se�ver main� Yes ❑No Condiiion.�%�{�� <br /> Does side szwer havc at least 19;slcpz from th�building lo ver main� [�Yes ❑No Desrn6e: <br /> Have ail bwiding ser�er drain connections to Ihe side ser:er b Ii n ident�iied and toca�z�? �Yes ❑{do <br /> Have all preperty storm dra�nage cennections b ihe side sew 1 been identified antl located? [�( Yes ❑ �'o <br /> Nas rrop=_7,6een evalualed(or tlramae2 defc:encies!vilh fi r,g;commonicated to prop=rty o�,vnw% �(]Yes ❑��o <br /> Installation Details: <br /> 4Vhat b/pe and brand of BWD v;as insfzlletl 2t Ihis site(Clean, i ec,c BV;�V,Grinder pump,etc.) ��. 1^�[� <br /> 'ai'here�eas Ihe device instal!ed(general description, attach m i )� , � ' .i_�. ' �'lf' � G _��_ <br /> �i�as there any other sewer or storm drainage v:ork cnmplete I conjunc(ion�vilh the BWD�aork�Is so ulezse tlescn5e: _, <br /> 1��C�'lf � <br /> � <br /> Installatinn Checklist: <br /> i��e all downspoufs and sde drainaga di;connecled Irom upst m ot Ihc 8W0� �Yes ❑�� Comment�'____ __ <br /> I <br /> Daes E3lND positioning meels minimum stope requiremenf ot �;5� �.l'es L�No CommeNs: ______— <br /> i <br /> Can 6N�D ne pulled out for mspect!on and maintenanr.a a(ter isening Ihumb scree+� [�Yes ❑�o <br /> Is BI�VD locked into the proper position and ihumb screw f�ghf tl"� {�L Yes ❑No <br /> Ciicle Uie BWD cav �irrigafio��iandscap°area)!tratfi �.oad bear�ng cover(dnue suriac�)/aaess hatch(hwldino) <br /> !4'as oroperty owner���m the iecatwn of the inslalleo BV'JD ��Yes ❑No Commenis <br /> Propert},Owner's Signature���- Oate: � 2 � � S __ <br /> Insfaller's Signatwe. ( ,4? .� � Date t �^�S — <br /> u 1 � � <br /> Rew;inn� ? 1 Friday,September�z,z014 <br /> � - � <br /> _ , ._._ __.----- ._ ..-_ .._ <br /> ---- -— _. _—�----- --'---' ' <br /> I I <br />