4324 TERRACE DR 2016-01-01 MF Import

i BACI(WATER PREVENTION DEVICE FINAL � INSTALLATION CHECKLIST i , - � � i Installation ('�rraany Name and Contast Info: �l ��r1n�� y.��.��l�� ; Date Backvae'cr Prevention device(BWD)was installed: Date this form was completed: � Installation Property Owner Name and Contact Info: y3.��/ Tri�O« ��r.ri��' 4/4 5�Z�S � ! Property Address: � Pre-Installation Inspeetion ChecklisL i All items must be checked'Yes'in order for a BWD to be considered for instaflation Is there a basement or level of ihe house that is at or near assumed sewer main elevation?�Yes ❑No � Are there fixtures in the house located below the upslream sewer manhole rim elevation?{�]' Yes ❑No � Is the side sewer cuRently UNPROTECTED from se�ver backups(does not have a BWD installed)?�Yes ❑No ; i Site Inspection Checklist: ' I All items must be checked'Yes'be%re inspection is considered complete ; Was side sewer 7V inspected from 6uilding to sewer main? �Yes ❑No Condition:�_ � I Does side sewer have at least t%slope from the building to sewer main? [�Yes ❑ No Describe: i Have all building sewer drain connections to the side sewer been identified and focated? e Yes ❑ No � Have all property storm drainage connections to Ihe side sewer been identified and localed? �Yes [�No � Has property been evaluated for drainage defciencies with findings communirated to property owner? �7es ❑No i Installation Details: ! What type and brand oi BWD was installed at this site(Clean Cheok BN1V,Grinder pump,e�c.): t"/�„ !'��Y j- Where was the device inslalled(general description,attach map)? yZ[L � '�'Yh'/ !Jr.lo�r�_ _ j I Was there any other sewer or storm drainage work completed in conjunction with the BVJD wor�?Is so please descrihe:_ i Installation Checklist: Are all downspouls and site drainage disconnected from upstream o(the BWD? �Yes ❑No Commenis: ' Does BWD positioning meets minimum slope requirementof>1%? B.Yes ❑ No Comments: � Can BYJD be pulled ouf for inspection and maintenance after loosening ihumb screw? ["�Yes ❑No i Is BIND locked into the proper position and ihumb screw tightenad? .'[C]Yes ❑No � ' Cirde the BWD r.over: irrigation cover(landscape area)l Uaffic load bearing cover(d�ve suriace)1 access hatch(building) I Was property owner shown the location of�ne installed BWD? Yes ❑No Comments: � � , ,.... _.. � '/; ./' �--,i \ . Property Owner's Signature:`� /C"�- �—'� - Date: � � `? � � �y I Installer's Signature:��,� Dafe: �/—L'�/y � ; I Revision:2 1 Monday,September 15, 2014 � I � ;