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! <br /> f <br /> Tl�3a7a � <br /> �/ � I <br /> . j1e�,^r:7i'� W 3a.. ��i13U.--,����n�-��-f-�� I <br /> . � <br /> � BACKWATER PREVENTION �EVICE FINAL i <br /> INSTALLA710N CHE�'KLIS7 � N�O�ym 5ti, G;y�y � <br /> i <br /> ; <br /> Inslalla6onCompanyNameandCcnta�!Into: �� Al�u Pl��htiil� �' 11r�l�hn t�"t-� ��� �ay�y - � <br /> Dato Eiachvater Prevention device(BWD)�vas installed:.4-1�-�i S Date thls form wa's compieted: ; <br /> � <br /> Instzliation Praperly Owner Name and Contact Into: ;'z� '- -�e� �i ti���� -� �� — { <br /> Property Address: I q 0 L ���-�c 1��-�e �' r�''-� f�9�I`�'LJ � <br /> Pre•Installatlon Inspection Checklist: j <br /> A!I items must 6e checked'Yes'in orde:for a BVYD to be considered tor fnstallation ± <br /> Is there a 6asemenl or level of the house that?:at or near assumed see;er main elevalion7�Yes ❑No � <br /> Are there fixtuces in the house located beloe�!h�upsiream seerer n��anhoie rim elevation'?�,Yes ❑No i <br /> Is the side sewer currently UNPROTECTED irum se�,rer backups(does not have a BWD installed)7�Yes ❑No i <br /> Site Inspection Checklist• ; <br /> NI items must be checked'Yes'6efore inspecL'on is a. „Jerad comp!ete ? <br /> VJas sids sev,�erN inspeo'ed from building to;ee�er main? �Yes ❑No ContliBon: ; <br /> Does�ide ser+er have al feast 19b siopa from ti�e 6uilding to sewer main? �,Yes ❑No Describe� � <br /> � <br /> Hava all 6uilding seerer drain connecliens to the side sev;er�een idsotified and located? �Yes ❑ No { <br /> Haeo all property storm drafnage connections to ihe side sewer been idenfi(ied and Iocated? �Yes ❑No � <br /> Has propedy heen evaluated tor drainage defciencies�vith findings communicaled to propedy owner7 �Yes ❑No � <br /> Inslallatlon�etails: i <br /> What ty�pe and brand of E3WD e�as installed zt ihis site(Clean Check B�AN,Grinder pump,etc.): C �-��� i <br /> Where vras the device installed(general description,aitach map)? '�a�f,�JL��� �l�� � m � �G h_�„�. ! <br /> I�lliA 41.L�1,1/�1114r �' -e11C1� -- f <br /> f <br /> Nlas thera any other see+er or storm drulnago e+ork completed in conjuncflon wilh Ihe bWD v;ork7 Is so please describa_ ` <br /> _R�l��r�(��.�iLSi�1-LE:-��Paua.�'�.ti».-o_�-ta�- � <br /> Installalion Cliecklist: ,,,___,,,/// <br /> �—Ara alf downspouts and sile drainage d'+sconnected from upstream of the I3WD? �C1 Y"es ❑No Commonts: ' <br /> $Do2s BIND positioning meets minimum slop�requirement of>1457 �Yes U No Commenls: � <br /> —Can BWD be pulled out for inspoction and mainlenance atter loosening thumb screvr? �Yes ❑�o � <br /> �Is 3WD lo�'�ced into U�e proper posi;ion and Ihumb screlv tighlened7 �Yes ❑No � <br /> i <br /> `, Cirde ihe B���D cover:irrigation cover(landscapo area)1 lraflic load bearing cover(drivo sudace)1 access hatch(building) j <br /> IhTas propedy owner shown the location of'.:�e installed BN'D? �Yes ❑ No Comments: � <br /> /� ���W�Z�i S- I <br /> Property Ovmers Signalure:��� ��/�"�� �ate: � <br /> Inslaller's Signalure:�lu �" '� Date: -13�2(�� � <br /> Revislon:2 1 Friday,September 12,201� � <br /> i <br /> _ I <br /> 1 <br /> _ � <br />