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• � J...' . <br /> 6ACKWA�'ER PREVENTION DEVI�E FINAL <br /> IN�TALLATION CHECKLIST <br /> Installation Company Name and Contact In o: `-►�►�'�OB6Lt.`S �1.�MBI�h , �N( , <br /> Dale Backwaler Prevention deviCe(BWD)V�as inslalled: 11 3 I Date this form was completed: l� �2� <br /> Inslallation Property Owner Name and Cor,act Info: �VM�l 2u5�N�. <br /> Property Address: 2 � �E }�Q ✓L�R� W� � �s l0 <br /> Pre•Inatallation Inspection Checkllst: <br /> All ifems must 6e checked 'Yes'in order lo a BWD fo be considered lor insfallation <br /> Is'there a basement or level of the house tf�t is at or near assumed sewer main elevation7 , es �No <br /> Are Ihere fixtures in the house located beloVv the upstream sewer manhole rim elevationl es ❑No <br /> Is llie side sewer currently UNPROTECTE4 from sewer backups(dces not have a 8WD inslelled)7 es ❑No <br /> Site Inspection Chncklist: I <br /> AU items must be checked 'Yes'be/ore insp�eclion is consldered complete <br /> Was side sewor N inspected from buildingito sewer mein7 es ❑No Con ition: _�'�1615� <br /> Does side sewer have at least 1%slope fro�n the building lo sewer main? es ❑ No Describe: <br /> Have all building sewer drain connections t the side sewer been idenlified and loceted7 [�'�es ❑ No <br /> liave all property storm dralnage connectio s to the side sewer been identifled and located7 'es ❑No <br /> Has property been evaluatod for drainage d�ficiencies with findings communicaled to property owner? es ❑ No <br /> Installation Details: i <br /> What type and brend of BWO was instalie��t this site(Clean Check BWV,Grinder pump,etc.): CIEAr► Ci�fGK— <br /> Where was the device installed(general de cripfion, aKach map)7 M�P�P A'C'1�P�ari� <br /> Was ihere any olher sewer or slorm draina e work completed in con�unc:tlon with the BWD work? Is so please describe:iJ(7 <br /> � <br /> Installation Checklist: <br /> Aro all downspouts and site dreinage disconnecled from upstream o(the BWD? es ❑No Comments:__. <br /> Uoes BWD positioning me�ls minimum slopie requirement of>1�? m�❑ No Comments: <br /> Can BWD 6e pulled oul(or inspection and�ainlenance after loosening lhumb screw7 � ❑No <br /> Is BWD locked into the n and humb screw lightened7 es ❑ No <br /> Circle the BWD cove irrigation cover(land�cape area raflic load beari cover(drive surface)I access hatch(building) <br /> NJas property owner shown the oca ion of t�ie inslalled BWD7 es ❑No Commenis; <br /> �pro�rty0wnor's'Sig`n_ature ;�D'ale:�(Z Zy ZO� <br /> Inslaller's Signalure: Dele:_( ZS � <br /> Revision: 2 1 Monday,September 15,2074 <br /> i <br />