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� BAQ�KIMATER PREVENTION DEVICE FINAL <br /> � � RNSTALLATION CHECKl.IST <br /> � <br /> � — <br /> i � (� <br /> Ins(allation Company Name and Contact Into:_ � ,Q r�� ���"y CLi�S 1"L l�,1.�;ti Ip�(����_ <br /> Dale Backtivater Prevention device (8WD)was inslalled� 21— �� Date this form va completed:��Z� `�� <br /> �liistall5lion'Frop'_erty:Owrie�_�am`e and Conlactlnfo• ���y�_—��.Q ��_ <br /> (f?roperty.Addres`••s � � � ��1 � <br /> —�z-'-tc��'��,I�T�V�CS'. W O� <br /> Pre-Installa'tion Inspection Checklist: <br /> AI!dems m�lst be chr.cked 'Yes'in order for a�WD fo be considered(or instalfation <br /> Is there a b�sement or level of the house Ihal is al or near assumed sewer main elevalion� s ❑No <br /> Are lhere 6xtures in the house located below Ihe upsiream sewet manhole rim elevalion? Yes ❑ No <br /> Is Ihe sitle s�wer currentiy UNPROTECTED trom sewer backups(does not have a BN1D installed)? Yes ❑ No <br /> I <br /> Site Inspection Checklist: <br /> Allilems musf he checked'Yes'6e(ore inspection is considered com lete <br /> Was side seiver N inspected from buildinc� lo se��:er main? Yes ❑ No Conditinn: <br /> Does side sewer have at least 'I% slope (rom lhe building to sevaer main? � es ❑ No De cribe: <br /> Have all huilding sewer drain connections to 1he side se�ver been idenli(ied and located? Yes o <br /> Have all proRerty slorm drainage conneclions io the side sewer been identified and located? Yes ❑ No <br /> Has propert�been evaluated for drainage deficiencies wiUi(indiny:communicaled to property owner? es ❑ No <br /> Installation �etails: ,, Q <br /> 1�Vhai type aiid 6rand of BWD was inslalled al ihis si CIeSn Che�1 V, Grinder pump, etc.):C�. �f�� <br /> 4Vhere voas Ihe device inslalled(generai description,allas nn5p)? e�/�. „ �p(-(�-��� � <br /> , <br /> i �— - <br /> lNas Ih�re ariy olher sewer or storm drainaye work completed in conjunclion with the OWD workl Is so please describe:� <br /> Installalion Checklist: <br /> Are all downspouts and sile drainaye disconneded from upslream of lhe BWD? es ❑ No Comments: <br /> Does BWD phsilioning meets minimum slnpe requiremenl ot>1%? Q-Y s <br /> ❑ No Comm nls:______ <br /> Can f3WD be pulled oul lor inspeclion and maintenance after loosening ihumb,screw7 - es ❑ No <br /> Is 4N��locked inb the proper osilion and Ihumb screw tighlened? , es ❑ No <br /> CirGe Ihe BN��covr . � , ; cnv (landscape are2)/traffic load hearing cover(drive surfaee)1 access hatch(building) <br /> 'A�as propertyiovmer sh n of Ihe installed BWD? [�Yes�[] No Commenis: <br /> i <br /> `roperty Owner's'Signature'.� � ����� / <br /> 7`�- -t__ �L.ale:�t�/ C>/7 <br /> Ins(alier's Signalure: Dale: Z� I� <br /> Rcvision: L I 1 <br /> . Manday,September 15 )f71a <br />