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BACKWATER PREVENTION DEVIC;= FINAL <br /> INSTALLATION CHECKLIST <br /> ��r� ccxn �.�+�, c. � ����dc� Sc,��, L LG � <br /> Ins�allationCompany NameandContactlnlo:S�C� (�14�'�)�44-��i�/�rf ��`y,lr (-��L�•��I 1��,� <br /> Date Backr�ater Prevenlion device(BWD)was installed:__���,Date this'orm was completed �� . �_ <br /> . <br /> Instaliation Property Owner Name and Contacl Info:�(lll �1�1 �C(Nl _< <��=y•3��__ — <br /> P�operty Address:��I�l 1;'���CP�f_1d,.�._— U�,Yf���/�i,�} ����(�� _ � <br /> Pre•Installation Inspection Checklisk <br /> A�l items must be checked 'Ves'in order lor a BWD to be cunsidered/or insta'latron <br /> Is there a basement or leve'o(the house that is at or near assumed sewe�main etevaUor?�Yes � No <br /> Are there fixtures in the hcusc Iccated belov�the upslream sev�er manholc rim e'evaDon? �s ❑ No � <br /> Is!he side sewer currently UNPROTECTED frcro sea�er backups (does net have a BUVD installed)7 �es ❑ No <br /> Site Inspeetion Checklist: <br /> A!1 items must be checked 'Ves'befor9 inspechon is considered complete <br /> !Nas side see�er TV inspected from L'uilding lo sewer main? ���'es ❑P!o CondAion: _��_ _._ _____..__. <br /> Dces side se:ver have at least 1%siope from ihe building b sewer ma�n? �Yes ❑ No Descnbe: <br /> Have a'I buiiding se�:�er tlra!n conneclions to the side se�l�er been identifed and Iccafed? �es ❑No <br /> Have all property storm d�ainage connoclions to ihe side sev+er been idenii ied and localed? {-��s ❑ No <br /> Has property heen evaluated for dramage defciencies wilh fintlings communicated to property otimer? �Yes [] No <br /> Installation Details: C �� <br /> 4�'ha;type and brand ot BWD�vas installed at this siie(C!ean Check BWV, 6rinder pump, etc.)� '�'�__, 7"cs � <br /> 1^lhere was the device instal'ed (general descnphon, altzeh map)� �,��' X � . � "�-�,��.���,ti��� <br /> Nlas there a�•y other seaer or slorm drainaye Koik completed in conjunctlon with the BWD v�ork'? Is so p'ease describe: _ <br /> ---- - ._1�1c:L��L!� __ ---- <br /> Inslallation Checklist: <br /> Are all dnvmspouts and sile drainage disr.onnec�ed irom upslream of the RUJD? DYes ❑ No Commenis ___. <br /> Does BWD positioning meels minimum slope requirement of>1°6? �Yes [� No Comments <br /> Ca� B1NU be pulled out for inspection and maintenance afler lonsening thumb screw� {Q Yes U No <br /> Is BWD locked into ihe proper posilion and ihumb screw tightened? �es [� Nc <br /> Gircle Ihe BWD c�ver. irrigalion cover(I�ndscape area)I Iraffic load beanng cover (dnve surlace)I ar.cess haich (build�ngj <br /> i" <br /> bVas property owner shou�n Ihe localion of ibe installed BWD? (�]�l'es ❑ No Commenls _ <br /> Property Owner's Sign ture _ C �,�_�i� Date: __ � •�� �s <br /> / ,� v , 1� <br /> 'nstaller's Signature:.-��- "�-t,J - — -----.-- -----_ -- Dat�: _1�=___z�- --___- <br /> `1 <br /> Rrti��sion: 2• t �riday, September 12, 2014 <br />