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i <br /> � <br /> �ACKW//�7ER FF�EVEN'TlON DEVECE FINAL � <br /> � <br /> INSTALLATION CHECKLIST <br /> i <br /> � <br /> Installailon Company Name and Confact Info: r��11n PI� � ��`1��u.; ? <br /> Date Backvraler f'revzntion device(BVJD)��+as installed: S���t�- �5_Date this form was completed: S -�- fs i <br /> � <br /> Installation Property Olaner Name and Contacl Inio: �-�-Gv ����c� �,����c. --- � <br /> �— . <br /> Prope�yAddress: 1�"II � Lo;.,nb,- �9 f�.�t'- — - - -- i <br /> Pre-Installation Inspection Checklist; ' <br /> NI!items must be checked'Yes'in order for a BWD to be consideren forinstal!ation � <br /> is tnere a basement or level oi the house that is at or near assumed sev:er mGin elevation?�Yes ❑ ho � <br /> Hre there fuiures in the housa icrated belor�ihe upstream sewzr manhofe rim e!evation?[�Yes [�i No f <br /> Is the side sev�er currenUy UIPROTECTE�J irom s:vrer backups (d�s not ha��e a B1ND inslalied)1�Yes ❑ No � <br /> � <br /> Site Inspection Cheekl�ct; i <br /> ,ill itens must be checked'Yes'6efor�inspection is considered complete � <br /> 11'as side sev,er N inspected trom building to se�,ver main? �Yes ❑ No ConCition: _ ; <br /> Does side s=tiver have at IeasS 1'/o slopa from the building f�se�ver ma�n? [/�Yes ❑No Describe:_ ; <br /> Have all buildin�se�ver drain connections to the side sev;er been identified and locaied? � Yes ❑ No f <br /> Have all property storm drainage connections lo the side sevrer been id2ntifed and Iocafed? �Yes ❑ No , <br /> tias property been evaluated for drainage def ciencies v��in findings communieated to properfy o�;�ner7 �Yes ❑ No i <br /> . <br /> —. � <br /> Installation Details: � � ! <br /> lNhat tyoe antl brand ef BI��D was ins!alled a�this sit (Clean Check 9VJ�, Grinder pump,elc.): � <br /> VJhere was the de��ice instailed(general descripfion, a a�h-map"J?J I�X`� ���i c9 Z2P l��ti� �cc`��"'�' i <br /> Was there any other se�.ver or slorm drainage�vork completed in conjunction�,vith the BWD rork?Is so please descnbe�_ � <br /> �.t O <br /> � <br /> Installation Checklist; i <br /> Are all dov+nspouts and site drainage disconnected from upsfream of the BN,�D? �Yes ❑ No Commenis: � <br /> Does BIND positioning meets minimum slope requirementof>1°io% �]Yes ❑ No Commenir. � <br /> I <br /> Can 614�D be pulled oul tor inspection and maintenance after loosening thumb scre�v? (�Yes ❑No ; <br /> Is QWD locked into the Ret-gositl�ri-atntthumt`screv�tightened7 [�]Yes ❑ No � <br /> Circle 1he BWD co er. irriga6on crover(landsca e.area)I Ua(fic load hearing cover(drive sur�ace)I access hatch(building) � <br /> Was property owna .. own-the�ocation ot the insialled BWD? �Yes ❑ No Commenis <br /> i <br /> Properiy O�vners Signature:_ Date: : <br /> Installers Signature: Dale: � '� —�� i <br /> Revislon: 2 1 friday,Sep[ember 12,2014 <br /> _.� <br />