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� <br /> 1 <br /> BACKWATER PREV�NTION DEVICE FINAL <br /> ; <br /> INSTALLATION CHECKLIST i <br /> I <br /> i <br /> Installation Company Name and Contact Info: f�yci//� �''/w� i>> % <br /> Date Back�valer Prevention device(BWD)was installed: ,'/i�/i,� Date lhis form was completed: 3 �� i i <br /> Inslallation Property Owner Name and Contacl Into: GJ/c�j� S•iGtL'rd � <br /> I <br /> Properly Address: %�/2� i,o/l3,`/ � <br /> Pro-lnstallation Inspection Checklist: <br /> All items must be checked'Yes'in order(or a B WD to be considered(or instal.�alion �. <br /> i <br /> Is there a basement or level oi the house that is at or near assumed sewer main elevalion?�jNes ❑No <br /> Are there 6xlures in the house localed below the upsVeam sewer manhole rim elevation?['�J Yes ❑�No <br /> Is the side sewer currently UNPROTECTED from se�ver backups(does not have a 8WD inslalledj?.�Yes ❑No <br /> Site Inspection ChE!cklist: � <br /> All ifems musf he checked'Ves'be(ore inspecGon rs cansidered co e � <br /> Was side se�ver N inspected(rom bui�ding to sewer mainl Yes ❑No Condition: i <br /> Does side sewer have at least 1%slope from the building lo sewer mainl�l Yes ❑No Describe: <br /> Have all building sewer drain conneclions to the side sewer been idenfifed and located? �Yes ❑ No <br /> Have all property slorm drainage cronneclions to Ihe side sewer been identified a�d locatetll�Yes ❑No <br /> Has property been evaluated for drainage de6ciencies with(indings communicaled to property owner? �Yes ❑No , <br /> Installatlon DeWlls: � � ' <br /> What type and brend of BWD was instailed at this site(Clean Check BV�N,Grinder pump,etc.j: I�✓� t3LJ V Cj��L„_ry,��� , <br /> Where was Ihr.device installed(gene2l description,attach map)? _J�i���., -�� 4�u,/s �n R�.�/i ', <br /> !iG {ruL�>u � 'n// !A jnn7/n9 � <br /> i�Jas ihere any olher sewer or stortn drainage work compieled in conjun�lion wilh ihe BWD workT Is so please describe:_ I <br /> q/t'/ <br /> Installalion Checklist: �' <br /> Are all downspouls and site drainage disconnecled from upslream of the BWD7 �es ❑No Commenls: ! <br /> Does BWD posiGoning meels minimum slope reyuirement af>190? �Yes ❑ No Commenls: � <br /> Can BWD be pulled out for inspecGon and maintenance aflar loosening lhumb screw? f�Yes ❑No ' <br /> i ', <br /> Is BWD loc!ced into lhe,ptnpe�peei!' nami-ihumb screw ' ened?�]Yes ❑No <br /> Circle ihe BWD cover:i g�lion cover(iandscape area)I Uaffic�oad beariog cover(drive surface)f access hatch�bullding) <br /> Was property o�vner shown the location o(lhe ms�Iled BWD1 ,�Yes ❑No Commenis: ! <br /> ��/ ,/ � <br /> Propnrty Qwners Si � • � —� ,%�� 3�ti/'//'� i <br /> Installer's Signalur � Date: 3�..5/ �.5� ; <br /> Revisioo: 2 1 Friday,Septem6er 12, 2014 � <br />