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P��:KiNA��R f'FZEV�i�I"90R! �EV€CE FIiVf�� i <br /> � <br /> 7 INiTALLA�'BOI�! C�-iEC6CLIST' ! <br /> ; <br /> , <br /> _ � <br /> Installalion Company Name and Contact In(o: /�i�G��G �/a�,-r R,.�a I <br /> Date Bac4water Prevention device(Bl4'D)was installed: ' �`� /� Date this form wa= comple(e9� �/ �S i.f i <br /> Inslallation Property Owner Name and Contact Info: .th�i/a GG'F ; <br /> Property Address: %1/G w�-i�c�c Av�� i <br /> i <br /> Pre•Installation Inspection Checklist: � <br /> N!I itenrs must be checked'Yes'in order for a BV✓D fo be considereo for ins(allatio i j <br /> Is there a basemenl or Ievei of the house fhaf is at or rear assumed se�ver main eievation?[ �s ❑ i�o � <br /> Are there rixtures in the house Ixated belo��r the upslream sex�ar marhole rim elevalion? J Yes ❑No ! <br /> Is ihe side se��aer currently UNPROTECTED from see,zr backups(does not have a BIND instalied)�1'es ❑ No ' <br /> Site Inspection Checklisf: i <br /> A!1 itenu musl be checked'Yes'before inspection is considered complete � <br /> l4'as side se�vzr TV inspec!ed from buiiding to se4ver main? �Yes ❑No Condition: � <br /> Does side seu�er have at 12ast 1°6 slope from the building to setia�er main? �Yes ❑No Describe: ' <br /> Ha��e all building sewer drain connections lo the side seeeer been idenlified and located? �Yes ❑ �o ; <br /> Have all property storm drainage connections to the side se��,�er been identified and localed� �'S'es ❑No i <br /> Nas property been ev2luated for drainage defciencies wilh findings communicated to property owner7�Yes ❑ No � <br /> Installation Details: i <br /> 4Vha�type and brand o(BWD vras installed at`his site( � n Che� rind�r pump, etc.): � <br /> l���here was fhe device insfalled(general description,altach map)? 3AG L �e•r ���_� <zi'�c.,-_. ' <br /> . _ _ � <br /> _ i <br /> � <br /> INas there any other sewer or storm drain2ge v,�ork completed in conju tion with �he BI�JD�vork? Is so please describe:_ i <br /> N" <br /> Installalion ChecklisL' � <br /> Are all downspouls and si e drainage disconnected irom upslream of iha 3WD? �es ❑No Commenls: � <br /> Qoes BWD positioning meets minimum slope requirement of>1%? [�'�'es ❑ No Comments: i <br /> Can BIWD bc pulled out for inspection and maintenan�e afler loosaning thumb screw? �'Yes ❑ ��o � <br /> / � <br /> Is B�A�D locked inlo ihe proper position and thumb scre��.�tighlened? [�J Yes ❑ No � <br /> i j <br /> Circle the BWD cover�f g�a io�n cover Qandsca� pe a�trahic loa�;bearing cover(drive surface)f access halch(building) j <br /> 4�1�as property otvner shown itie foca ion o e installed OIND? �Yes ❑ No Commenls: ' <br /> � i <br /> Property O�vner's Signatu � � __ � Date: �v ; <br /> Installers Signat Q: i\��`�-�_._` Date:���S�.S'� <br /> Revision:2 1 Monday, September 15,2ui4 I <br /> I � <br /> I <br />