2727 VIRGINIA AVE 2016-01-01 MF Import

� � BACk�IVATER PREVENTION DEVICE FINAL INSTALLATION CHECKLIST Instzllation Company Name and Contact in(o: �"\� 1\h �`l� C) �� Date Bac6�vater Prevention device (B41'D) v,as installetl: �� 7� � SDate this form was completed: %" ��t" � � Installation Property O��ner Name and Conlaet Inio: _�r� �N-2 �� h r G l�rA w� PropertyAddress: ��2 �I�T � � Pre-Installation Inspection Checklist: Alf items must be checked 'Yes' in order for a L�WD to 6e consider�d tor Insfallafion Is there a basement or level oi ihe house that is at or near assumed sewer main elevation? � Yes ❑ �o Are Inere fixiures in the house located helotiv the upstream sev�er manhols rim elevation? �] Yes P No Is the side sevder currently UNPROTECTED from sewer backups (does not have a BWD instalted)?� Yes ❑ No Site Inspection Cheeklist: All items must 6e chocked'Yes' 6efore inspsction is considered complete lNas side sewer N inspected frvm building to sevaer ma�n? [, Yes ❑ No Condition: Does side se��aer have at least 1°6 sl�pe from the building to sewer main? W Yes ❑ No Describe: Have all building sewer drain connecllons to the side sevaer been identified and localed? [�] Yes ❑ No Havo all properiy stom� drainage connections tn the side sewer been identifietl and located? [J� Yes ❑ No Has properly heen evaluated for drainage deficiencies v+ilh findings crommunirated to properiy o�,�ner7 � Yes ❑ PJo Instaliation Details: What rype and brantl of 81h'D was inslalled al lhis site Clean�Check BIMJ, Gr der pump, elc.): �Vhere was lhe device ins�alled (generai descriptior, attacn map �_t (a- �,, �.� '��f �^ ��u' Was there any other se��er or storm drainage work completed in conjunclion with ihe �UJD work? Is so please describe: _, Inslallation Checklist: Aro all do�vnspouls and sile drainage dlsconnected from upstream of the BWD? dYes ❑ No Commenis: _, Does BWD positionirg meets minimum slope requirementof>1°�! � Yes ❑ No Comments: Can BN'D he pulled oul lor inspection and maintenance aRer loosening Ihumb screw7 �� Yes ❑ No Is BWD locked inlo the proper-g/osi�Ipo-amtlln�mbsc �ew Ughtened? [�] Yes ❑ No C'rcle the BWD coe r, irrigatioh cover (landscape area)1 i)iaffic load bearing cover (drive surface)1 access hatch (buiiding) Was property owner shov,m �1ocaHon-of-ihe inskellect8(ND? ��Yes ❑ No Comments: Propert; Ov+ners Signature: Dale: InstallersSignature: - Date:�_�� " �5 Rcvision� 2 �� Ftiday, Scptemhcr 72.2014