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BACKWAI�ER PREVENTION DE��/ICE FINAL <br /> IN:iTALLATION CHECK'LIST <br /> � <br /> �nstallation Company Name and Conlact In(y: C���ll,'S 11�h�1s{N�� �N[ . <br /> Date BacMvafer Prevention device(BWD)vJ,as installed: 1 I -� -1 Date this torm was completed: � '•g 'j S <br /> Installation Prop-�iiy Ov,nPr�dame and Conty3ct Infa ('�wEa�0�-y a K-f ��l'hP�*� <br /> Property Address: S 4O�i C U�-Dy RJ'� .� �J�� wta ��7.�1 - <br /> Pre-Installation Inspection Checklist: <br /> All�lems must be checked'Yes'in o�der(or a BWD to 6e considered(or installafion <br /> Is lhere a basement or level of the house that is at or near assumed sewer main elevation? es ❑No <br /> Are there fixlures in the house located belo�+ihe upslream sevrer manhole rim elevalion7[�'�❑No <br /> Is Ihe side sewer currenlly UNPROTECTED:from sev:er backups (does not have a BWD installed)? �].14��No <br /> Site Inspection Checkllst: <br /> Ail ifems must be checked'Yes'before inspeclion is considered comp le <br /> Was side sewer N inspected from buiiding to sewer main? es ❑No Condition: <br /> Does side sewer have at least 1%slope,from the building to sewer main7 es ❑ No Describe: F'i c�-`'� <br /> Nave all building se�,�er drain connections to�the side sewer been identi(ied and localed? es ❑No <br /> fiave all property storm drainage connectior�s to the side sewer been identifed and located7 es ❑ No <br /> � Has property been evalualed for drainage defieiencies with fndings communicated to property owner? �1`c�No <br /> inslallation Details: <br /> What type and brand of BWD was installed al ihis site(C!ean Check BWV,Grinder pump,etc.): CI,F�Pti1 Ct�I�n.IL <br /> Where was the device installed(general de;cripllon, attach map)? �� �"f"i�GL-f�� <br /> Was lhere any other sewer or slorm drainage work completed in conjunction wilh the BWD work7 Is so please describe: /�J <br /> Installation Checklist: <br /> Are all downspouls and sile drainage disconnected Irom upslream of,�the�B�W�D7 es ❑ No Commenls: <br /> Docs 61��D posilioning meets minimum slopie requirement o(>t%? (�yYgs LJ No Commenls: <br /> C�n �WD be pulted out lor inspeclion and maintenance a(ter looseniny ihumb screw7 ❑Yes ❑ No <br /> •: Is OWD lucked into Ihe proper position and Ihumb screw tightened? es ❑ No <br /> Circle the BWD cover, irrigation cover(landscape area)1 tra�c loatl bearing cover (drive sur(ace)1 access hatch(building) <br /> Was properfy owner shown l a localion ot tti in a led BWD? es ❑ No Commenls: <br /> rPro`perly,Owner's 5ignature:_ ` `V�l'�'�- �Date:-" '� �(�� <br /> Installer's Signature: Date: � — -?�1- <br /> Revision: 2 ' 1 Mnnday,September 15,2014 <br />