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I <br /> � <br /> BACKW!►TER PREVENTiON DEVICE FINAL � <br /> (NSTALLATION CHECKLIST ; <br /> , <br /> � <br /> , <br /> ; <br /> � <br /> Installation Company Name and Contact Inio: L`��n��(� ��u�1���k-� ; <br /> Date BacMvaler Prevention devico(BWD)was installed: S � -l5� Date this fortn was comoieted: S"- � ��� I <br /> Installation Properfy Ov��ner Name and Contact Info: �-'!arol�C I-�u��u-Cy _ � <br /> PropertyAddress: I �U'�- �^'�ap�-C 5�- ��.c�z���i �rJ� �(�'�� <br /> � <br /> Pre-Installation Inspec6on Checklist: � <br /> All items must bs checked'Yes'in order(�ra BV✓tJ to bs considered(orinstalfa8on ; <br /> Is ther=a basement or ievel of the house that is at or near assumed setirer main elevation?�Yes ❑No � <br /> Are there fixiures in the house lorzted belo��r the upstream se�ver manhole nm ele��ation?f�]Yes ❑ No <br /> Is the side se�ver currenUy UNPROTECTED from searer backups(does not have a BWD instailed)?�]Yes ❑No � <br /> Site Inspection Checklist: � <br /> All items must 6e checked'Yes'before inspecGcn is considered compfefe l <br /> Was slde setver N inspecfed from building to sen�er main? �Yes ❑ No Condition: � <br /> i � <br /> Does side setti�er have at least 1%slope from the building to sevrermain? �Yes ❑No Descri6e: <br /> Have all building se�var drain connections to the side se�ver been identified and localed? �]Yes ❑ No ' <br /> Have alI property stortn drainage connections to the side se��rer been identified and located? (�Yes ❑ No � <br /> Has property been evaluated for drainage deficien�ies v+ith imdings cammunicaled to property oivner? � Yes ❑No ; <br /> Installation Details: ^ ' <br /> lNhat type and brand oi BIND�vas insfalled at this site lean Check BINV, 'nder pump, efc.}� � � <br /> 1h�here v:as the device installed(general description,attac� map)? �h ���U�Q ��.o�ns-�. �y/-GSpb����(�-ya.�� ' <br /> t <br /> lh�as there any other se��aer or sterm drainage�work completed in conjunction with the B���D work?Is so please descnbe:_ ' <br /> r`-- U � <br /> � <br /> InsWllation Checklist: � <br /> Are all downspouts and site drainage disconnected from upstream of the BYJD? �Yes ❑ No Commenls: � <br /> Does BWD positioning meefs minimum slope requi;ement of>1%? �Yes ❑ No Commenis: j <br /> Can BWD 6e pulled out for fnspeetion and mainlenance after loosening Ihumb screw? �Yes ❑ �o ; <br /> Is 81ND ixked inlo the proper posi6on and thumb screv�ticul tened?--�-Xe�_[�LJ�` � <br /> I <br /> Circle the BWD co��er: irriga6on crover(landscape are�N-�affic load 6earing cover(drive surface) ccess hatcf�(building) I <br /> Was property o�vner shown the locatioo of the inslalled BIND? 0 Yes ❑ No Comments: <br /> Property O�mers Signature: Date: j <br /> Installers Signature:_ --�` Date: `� �� � �� ; <br /> i <br /> Revision: 2 1 Friday,September 12,2014 i <br /> I <br />