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I _N��y <br />��� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name ano Contact inio: �l �'i� �`��� �- <br />�ate Backwalet Prevention device (BVJD) was inslalled:�?� -� Dale this form was cornpleted: �7� 1S' <br />Installation Property Ovmei Name and Contact Info: CiU l� i c�o Ts %e �.L ( _-- <br />Property Address: � � � <br />Pre•Installatlon Inspection Checklist: <br />Alf i(ems musl be checked 'Yes' in order for a B WD lo be considered (or inslellaticn <br />Is ihere a basement or level of the house ihat is at or near assumed seeuer main elevation?�] Yes ❑ No <br />Are lhere iixtures in the house located below the upstream sewer manhole rim elevation�Yes ❑ No <br />Is ihe side sevier currently UNPROTECTED from sewer backups (does not have a BWD installed)?�Yes ❑ No <br />Site Inspection Checklist: <br />All items musf be checked 'Yes' before inspeclion is considered compiete � <br />Was side sewer TV inspectetl from building to see�er main? y[X�Yes ❑ No Condilion: � <br />Does side sevrer have at leasl i% slo�Se from the building to sewer main? �,Yes ❑ No Describe: <br />Have all building sewer drain connections to Ihe side sewer been idenfrfied and localed? [�,Yes ❑ No <br />Have 211 propert�� slorm tlrainage connectlans to the side sewer been idenlified and lo�ated? � Yes ❑ No <br />Has property been evaluated (or drainage defiiciencies wilh findings communicated to propedy owner? � Yes ❑ No <br />Instailation Oetails: ' �1 � �I��� ; <br />Vdhat rype and brand of BWD �vas installed al lhis sile ,Clean Ch BWV, Grinder pum etc.): � -�- -�* C.c � <br />Wi7ere �vas the device installed (general descri�tlon, atta � map)? ,� -"�'G ``'�� _ <br />Wes thore any othor sowor or siorm drainago work r,ompleted in conjunction �vilh the BWD �vork? Is so please describe: �� ' <br />Installation Checklist: <br />Are all downspouls and site drainage disconnected from upsiream of Ihe 8WD?� Yes ❑ No Commr,nfs: __ <br />Does BWD positioning meeis minimum slope requirement oh1°/o?,��Yr,s ❑ No Commenls: <br />Can BWU be pulled out ior inspeclion and maintenance after loosening thomb scre�v? �„Yes ❑ No <br />Is BWD locked into Ihe proper posi;ion and ihumb screw ti hleneci?�:Xes-�] No <br />Circle the BWD cover. irrigalion cover (landscape ar a I traffic load bearin�_c:ov��rive sudace) ! access hatch (building) <br />Was property owner shoedn ihe loca ' n of the inslalled BWD'? ,[� Yes ❑ No Comrnerls: <br />��, � � �lta �q��.� !�%e«�e� Date: �� y�.�,1--..__._ <br />Property Owner's Sigqa4�,�e:_ �--- <br />Insfaller's Signature: <br />Date: <br />Rovision: 2 1 Manday, September I5, 7.D14 <br />