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! <br /> I <br /> �AC6f11VA�'ER NREVEfVTION DEVICE FINAI_ � <br /> Q, ONSTALLATION CHECKLIST <br /> � <br /> i <br /> c-' ^f' J �al�' �7f'•r"Z-�'f L L.G � <br /> t'ti'l�f i Cccn �(� ;cJ I <br /> Instaliation Company Name and Contact Inic..T� C • �� [���`�4 -��'S�1! �'i i'rl� �"�L�):;��,'L� :�)Sf;,Z i <br /> Date 6aclnwaler Prevenlion device(BWD)was ins�alled: �r1 Cf � Date Ihis form was coinpieted:�� � � <br /> Inslallation Property Owner Name and Contact Info:�,_L.{,lC�,/d�t<I � �"rn ���� —r�/LZ`�,-I�-�T i <br /> Properly Address �. � �� l,Y.�C? �-�,�-"� �J P/L.P� ��2-('� � — j <br /> i <br /> Pre-Installation Inspection Checklist: ! <br /> Afl rtems must 6e checked'Yes'in order for a AWD to be considered for installation ; <br /> Is 1� ere a basemer.t or level of fhe house Ihal is al or near assumed sewer main elevalion? (�J Yes ❑No � <br /> � <br /> l+re the�e iixlures in ihe house located belov�ihe upsiream se�ver manhole rim elevaUon? [y�Yes ❑ No ( <br /> Is the sitle sewer currenUy UNPROTECTFD from sewer backups (does not have a BWD installed)? �Yes ❑ No � <br /> Site Inspection Checklist: + <br /> ; <br /> All rtems must be checked'Yes'hefae inspection is consrdered compfete ; <br /> Was side sewer TV inspecled from buiidinc�to sev�er main? �Yes ❑ No Condition: _ �S�`�,'fl�-�'— ( <br /> Du�s side se�ver have at least i%siope from the building to sewer main? �'Yes ❑ No Describe: � <br /> Have all bui!Jing sewer drain connections to lhe side sewer been identified and ie:aled? [�Yes ❑ No � <br /> Flave all property srorm drainage eonneclions to the side sec�er been identified and localed? ��Yes ❑ No � <br /> Has property been evaluated(or drainage deficiencies�vith fndings communicated lo propedy owner? �Yes ❑No � <br /> Installalion Details: ': <br /> What type and brand of DWD v�as inslalletl al this sile(Cleao Check BWV, Grinder pump, etc.): �1` �C' : <br /> Where was the device insialled (general descripiion, .ittar.h map)'? ,`�'0��� -"�=� ���� ' <br /> f <br /> lNas Ihere any olher sewer or storm draina,ye H�ork completed in conjunction with the OVUD e�ork? Is so please describe: _ : <br /> _ _ -_ I_� '�L---- - , <br /> --------- ----- , <br /> Instailation Che�klist: <br /> Are all downspouls and site drainaye disconnected irom upslream of the EiWD? (�:5�es [� No Commenls:_ <br /> 1 � <br /> Does BWD positioning meets minimum slope requiremenl of>t%? c(�]Yes ❑No Commenis:_____, � <br /> C2n BW�be pulled ouf ior insper.tion and mainlenanr.e aiter looseniny lhumb screw? (�Yes ❑No <br /> Is DWD lar.kcd inta lhe proper posilion and ihumh screw lighlened? �'Yes [� No ` <br /> Cirde the BWD cove . irnyation cover(lan�lscape area)!tra(fic loatl 6earing r.over (drive surface)I access halch(buiic!ing) ! <br /> �.._--:.-:_-. <br /> Was�roperty o��mer shown Ihe Iocaiion o(Ihe inslailetl B1ND? �.Yes ❑ No Commeids:______ <br /> �7 � � � � <br /> Properly Owner's Siynature: /�_ _ Date:��.��-��� ' <br /> Installer's Siynature:�._ �� /� __ Dale:_�/��' � <br /> Revision:2 <br /> -�i�-/ . . 1 friday, SeptemL �� l2,2014 � <br />