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, <br /> � ' i <br /> � <br /> �%� � ' BACKWATER PREVENTION DE�'ICE FINAL � <br /> ���� INSTALLATION ;CHECKLIST ` <br /> ` I � � <br /> � � <br /> , ; <br /> Ir;la!iaUon Company�ame and Contar,l Irfo _� i�� � C i � (� � <br /> :c�__�� LL � i"L.�i�11 �( � I <br /> I A.C --- <br /> Dalr. Rackvliater Prevention de�-ir.e (BWD)was�nsta'led.�' / 4 '�)`i Datc tnis(orm was r.ompleted._ � .� � � ! <br /> -- J-' _ - _� <br /> Ins(allahor Proporty Oerner Namc and Contact Info:�,�����{-�-L� ��-G��q i <br /> ��_=_ ___�� i- - ' <br /> PropertyAddress _�.(I_�_ .�Ar����Ci'G��I_�C'1.---q�� -- � <br /> P�ednstallation Inspection ChecklisY. ' <br /> �71 tlenrs m�sf 6e checked 'Yes'in order!or� f3WD to be considered/ol�insfall2fion <br /> Is Piere a basemenl or level of ihe house that is al or near assumed sewer main elevahon7 '� es (]Pdo <br /> /��e lhere fixlums in the housc oca!etl below ihe upstream sewer manhlole r�m efevat�on?C Yes [� No - <br /> �s I�,e side sEwer currenl!y UNF'ROTECTED from sewer bacMups(does not have a BVJD mslalled�? � es (� No i <br /> Site Inspect+on Checklist• � � <br /> i <br /> AI�dems mu�t be checked 'Yes'be%re inspr.ction is considered complele � <br /> l�'as side seYier �V �nspected(rom buddmg to sewei rna n? ��^(es ❑ No CPnifilion: • <br /> Uor,s sitle sev;er have at leasl 1"/� slope trom tre building to sewer mair�7 �}Yes T � ` <br /> �J No De�cnbe <br /> Have all buildin�se���er d�ain cunnect�ons Io,he side sewer Leen identi�ed antl located? t�es� No <br /> Have all property storm drainaye coQnechons fo ihe side sewer been id�ntified and localed? 0 Yes ❑ N <br /> t 1as propeity br.en evaluated(or dr�inaye deticiencies with findings communicated b property owner7 [_ Yes []No ' <br /> I I � <br /> Installalian Details: I <br /> Whai typr.an�J hrand of RWD was instaileJ af th�s site(Clean Chc�r.k �1Mi, Gnnder um , elc �c<� � <br /> v u ) _C--�rLG �s:�� <br /> vi��,ere was t�ie d?vir,e ins�alled(yeneral description, atidCh R1J�1�� 1':�r'-1�- _r��•._(•..;,�- --- - ---- - � <br /> 1 <br /> _ -------� -- -------------- —��---------- � <br /> 41�as Ihere any o;her se�ver or s(orm dra�nage work completed in conjuncltion with Ihe BWD wo�k,� Is co please descnbe ����l <br /> � <br /> _- - -- --- - ------ — — -- - � <br /> InstallationChecklist: j '�> �--'- -' : <br /> Arc �H dov;nspn,it;; an�site dra�nagc discormecletl from upstrcam uf Ih�,�/f3W h7 L Yes � No Comments ,��,.,,.,,��..,,.1 s <br /> D��es oWD pOsilionmg mects min�mum slope requirertlenl ol >1Yo? (fa'1'es � _� No Ct>i�fienls�� J{'�� "°0C'"��� <br /> Can BVJ�he iulled out lor inspection antl maintenance afler lonsening ihurnb sc�ew� ���PS �. �No � <br /> Is pWU locke�I into ihe proper posdion and scre�v hghtened'� ri�rYes [�� No <br /> .. C�rcle Ihe HWpI cover ii��q'��aSt�''[��.���.y�q�/y_trrI�n SGapC��e�)I Iraffic loatl hearing �over(dnve suriar,e) I aceess hatch bwldin � <br /> lNasprnpr.dyuwnr.rshowTthE�a,,ap- a'��_ �Ut_E_ � g� ` <br /> �dW�» ����[j No Comments i <br /> —_ -- j <br /> Propcity own�r's 5iynafure: ��i� �� /aD/r <br /> — Uafe: L— �1 , <br /> In,faPer's Sign�lure. _��� /,� �_ � � �- � <br /> -�-�=�'�!� '49�i� I ' Dale _� �.G. ; � i� <br /> N�v�����, :' I , , ---i--- -- -- , <br /> � � i �Jlnnday, SeptembPr IS, )014 � <br />