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BACKVVA�ER PRE\/ENTIOR� DEVICE FINAL <br /> E,• .F,T INS�ALLAT:ON �FlECKLIST <br /> Install2lion Company IJame and Contact Info: i�G%�i � r,r,/+�_ ✓.aT_��/LS� ��' — /S�7 <br /> Dace Bach�^a(er Prevention device(84VD)�,�as install=d:_/l�S/,>ei� Date this form e;as comp!e(ed: <br /> Insfallaiion Property Ovner IJame and Contar,t In`o: AG 7 0./ >;e���U� �/a 57 7S �/— �/3 5'G_ __ <br /> P;.�acny f�ra�CSS: /�G� JZl.�Cft P� v lir:e/ �' �---1$ ��'� <br /> Pre-Installation Inspection Checklist: <br /> All i(ems must be checked'Y'es'in orde;lor a Bbi�D fo b�cc:isitiared for insfa!�ation <br /> Is tnere a basement or level of Ih�house thai is at or near assumed see;er maln elevation? �1'es U I�'o <br /> k•r, �here Fixtures in the heus�Iccafed below;he upslraam sew•er manhote rim elevafion?�Yes ❑ I�'o <br /> s tne s�d2 s=rier curren(ly U'JPROTECT�D��c� sei.c�r b2��:;c�,;j;ir�s ,-,ot hs�:e; 9i'�!� ir;±al'a�;'-�l':-.�s �� �Vo <br /> Site Inspection Chzcklist: <br /> r�.'�:,'Cri15 R7U.S(�iz CriC�:2C1 '��p$�f?Ci�"C:;li�i��ii0p iS i;iR�i7�hiQ C.p:ii�ii:�B <br /> l'das side se�ver TV Insp��cted;rom b���idin�'.o ser:er main? ' , 1'es ❑ iVo Ce��d'�i���� __ <br /> Does side sewer ha:�e at lea�t 1 So slope irom;he bulltling to se�t��r main7 (�Yes j� Ido De:cri:;e L�. <br /> Have 211 building se���er drain connections lo the side sewer been idenbr�etl and localed? �, Yes Li h!� <br /> Have zll property storm drair.aae connections to the side se���er been idenii(ied and loealed? �] Yes ❑ IJo <br /> Ha; pronerty been evaluated for drainage da`i�iencies wilh findings communicaled to property olvner7 �1'es j� 'Jo <br /> Installation Details: <br /> P��hat type and brand of Bl4'D was inslailed at fhis '�e(CI., i �ec; Blv Grinder pump, e1c.) <br /> 11�here was the devir.e installed(general descriplion, at�ac i map)? ,N,,i.l i�;,ne c�� �'rc� �c�r� � <br /> �-----' <br /> l das lLere any other seerer or slorm drainage�Nork completed in conjunction e�ilh ihe BWD e:ork? Is so pl�ase desr.ribe: ,__ <br /> fJ/�i <br /> Instaliation CheckiisL <br /> A�e nil dovmspouts and sile drainage disconnecled from upsiream o(Ihe BWD? �l'es ❑ IJo Commenis <br /> Uoes BWD posifioning meels minimum slope requiremenl o(>t°�? f�1Yes ❑ Ab Commenls:,_________ <br /> C�n B14�D be pulled oul for inspection and mainlenance after'oosening thumb scre�v?�/'j Yes ❑ Nc <br /> I; BVdD locked inlo the proper position and thurr;b screw tightened? � Yes []No i <br /> Cirde the BWD cover irrfg'ai on co��er(landscapc area)1 traltic oad bearing cover(drive suriace)1 access halch (�.i idin�) <br /> '.:'as property owner sh�h Ihela�atio�af(he�`ns�lled B Vlf D? (�Ycs �_I �dn Comn�enfs: <br /> Property Ot��ner'� Signalure: �'w' _ Dafc:_ <br /> Installer's �i3nalu�s.__ _ — - Dale:��J�-S"" <br /> Fevision: 2 1 !vionday, Sco,ember 15,2U14 I <br /> � i <br />