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B��KWATER F�I�EVENTI�N DEVI�E FINAL <br />INSiALLATiOM CHEGKLIST <br />Insiailation Company Name and Contact Info: <br />Dale BacMvater Prevention devics (BVVD) was install d: "7- �-\ -1 �_ Data this form was completed: �� —� 5 <br />Installa6on Properiy Owner Nam� and Contacl Info: �.—�r�a� + a ltiC;, <br />Propsrty Addrass: �-���7 l) � rv�l��G � �' - <br />Pre•Installation Inspection Checklist: <br />l�II items must be checked 'Yes' in order for a 6lND to be considered lor instal,'aGon <br />Is Ihere a basement or level of lhe house that is at or near assumed sewer main elevalion? � Yes ❑ No <br />Are thzre fixtures in lhe house located beiov� Ihe upstream se:ver manhole rim elevalion? �] Yes ❑ No <br />Is the side sevaer currently UNPROTECTED from sev,er backups (does not have a BIND installed)7 j�J Yes ❑ No <br />Site Inspection Checklist: <br />Al! itents must be checked 'Yes' be(ore inspecfion is considered complefe <br />VJas side se�•rer N inspecled from building to se�a�?r main? � Yes ❑ No CondiGon: <br />Does side se�ver haJe at leasl 1"/o slope Gom the building to s�wer main7 j�] Yes ❑ No Describe� <br />Have all buiiding sewer drain connectlons to the side ses�er be:�n identified and located7 �] Yes ❑ No <br />Have all prope�ty storm drainage connections to the side sewer been Identified and located7 [�j Yes ❑ No <br />Has properiy been evalualed for drainage deficiencies with fndings communicated to property o�•mer? �] Yes ❑ No <br />Installation Defaiis: <br />�r�rf�at type and brand of BWD �vas inslalled at �his site I`ean Ch�i.ck BWV,� tler pump, e;�.]: _ <br />l'dhere was the device installed (general description, afiar.h ma�j?- "__��� a✓ cQ <br />lWas there any other sewer or sto�m drainage w�rk completed jy.conjunction wi(h lhe BVJD wor�? Is so please desr,ribr,: , <br />Inslalletion Checklist: <br />/ve all dovrnspouts and sile drainage diseor.necled irom upslream of Ihe BWD? �j Ycs [] No Comments: <br />Uces BWD positioning meets minirc,um slop� requirement of>t°/a? � Yes ❑ IJo Comments: <br />Can BUVD be pulled out for inspeclien and malnten��n�ro a(ter loosening thumb scre�a7 �� Yes �� No <br />Is BN'D locked into the �roperp s lion anc ;humb scieM tighl\ed? /{] Yes ❑ No <br />Cirde lhe BWD coVeLimgation cover (iandscape area) ! traifc�ad bearng cover (drive sur�ace)1 access hatch (building) <br />VJas properly owner shown the localion of Ihe'insl5lfea9VJDT �] Yes ❑ No Comments <br />� roparty Ovmets Signafure: � Dale: _ <br />Instailer's Signature: _ _ Dale: �" � ( 5 _ <br />Rr.vision: 2 ---�� 1 Friday, Septemher 12, 2014 <br />