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i <br /> �P.�f�9e�T�f� �REO/E�1lTiO�R 93�VI�� FIfVAL � <br /> � <br /> Ev €N�T�LL�'TiOi� CHE�KLlST <br /> � <br /> Instailation Company Name and Conf�ct info: M �L'"` f �kr��" k-1 �e2 S 76U FS�7G � � <br /> Date Back�:�afer Prevenlion deaice(BWD)�vas ins(alied: �- I I- � S Date this torm v,as completed: ,�- ��-1S ! <br /> Installation Pro ert Ovrner�ame and Contacl In(o:_ ��f� � <br /> P Y ro�,l, 5o,n �-f<2S - � f�i -`�(1r'`"� I <br /> Propert��Address: � S ,z�-1 �-.!c�r-.rn Av� �.�,-r�fi �,./f1 �i 5� 2 G � � <br /> Pre-Installation Inspection ChecklisL• ' <br /> All items must be checked'Yes'in order lor a BV✓D to 6e considered/or ipstallefron � <br /> Is there a basemenl or level oi the hous2 that is at or nezr assumed see�er main elevation?�1'es ❑No i <br /> Are there iixtures in the house located belo�v the upstream se�ver manhole rim elevation?(J Yes ❑ �o i <br /> Is the side seerer currentiy UNPROTECTED irom sev;er backups (does not have a BWD insiailed)7 �Yes ❑t��o � <br /> Site inspection Checklist: � <br /> AI .:.:>>s must 6e checked'Ves'before Inspection is considered cromplete I <br /> Was side sewer iV inspectetl from building to sevaer main? jk]Yes ❑ No Condilion: ���� `. <br /> � <br /> Does side sewar have at least 1%slope from the building to;evaer main? [3�Yec ❑No Descnbe: ! <br /> Haae all building sewer drain connections to the side sewer baen idenlified and located? �Yes ❑�b i <br /> Nave all propery storm drainage connections to lhe side�:.wer been identified and located9 �Yes ❑No <br /> Has prop�rty been evaluated for drainage deficienci�s�v�ih findings communicated lo properly a,vner? �Yes ❑ I�'o i <br /> Installation Details: � <br /> VJhat type and�rand of BWD was inslalled at this sile(Clean Check BWV, Grinder pump,etc.): ( fC� cl.t�-k _ i <br /> Vtlhere was the device installed(general descnpGon, atiach map)? i i� �?,�c�= �.c,�� I <br /> � <br /> I <br /> VJas ihare any niher sewer or storm drainaye work completed m conjunc(ion wilh the BN'D�;�ork'? is so please describe:_ � <br /> ---�.-��- - 1 <br /> Installatlen Checklis:: � <br /> Nre all do��rnspouts and sile drainage disconnected irom upsiream oi Ihe 81ND? �1'es ❑ No Comments: _ � <br /> I <br /> �oes BWD positiening meels minimum slope requirement of>1%? �]Yes ❑No Comments: ? <br /> Can BWD be pulled oul ior inspection and mainlenance a(ler lousening thurnb screva? �Y�s ❑ No j <br /> Is BVJD locked into the proper osition and thumb screw lightened? �Yes ❑No � <br /> Circle lhe BIND wver. igation c r(landscape aroa)I iraKc load Uearing cover(dnve surface)I access hatch(huilding) � <br /> Was prope'ty owner shctivn the Iccalion ot the installed BWD? �Yes ❑ No Commenis: ; <br /> I <br /> Property Owner's Signature: Date: � <br /> Instalter's Signature: �/� /� �'�-- _ Date: �- - � �` � S � <br /> Revision: 2 1 Monday,September 15,2014 j <br /> � <br />