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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Inslallation Company Name and Contad Info: �l� b n c L Z - Y�`i - vi c, <br />Dale Bacicwater P�evention device (BWD) was installed: �- 5�� Date ihis fortn was completed: 3'-� �-� S <br />Installation PropeAy Ovmer Name and Contact Into: �Y1N a-� lL- 1�., ��`�`^�� <br />Property Address: �o ! b� G uL h�-/ �� <br />Fre-Installetion Inepectian Checkist: <br />All flems must 6e checked'Yes' in order for a B WD to 6e wnsideted for instellaSon <br />�s there a 6asement or level of the house that is at or near assumed se�uer main elevatinn7 [�es ❑ No <br />Na there foctu�es in the house located 6elow ihe upstream sewer manhole rim elevetion? c�►'es ❑ No <br />Is tha side sewer curterttly UNPROTECTED irom sewer backups (does not have a BWD Installed)? ��fes ❑ No <br />Site Inspoction Checklist: <br />AII ((ems must 6e checked 'Yes'before inspectlon is cbnsidered oompkle <br />Was side sewer N inspected from building to sewer main7 �N�s ❑ No Condition: ��1�j ��� � L�'"C"�D <br />Does side sewer have.at least 1"/o slope from the building to sev�er main? [�]�f`� ❑ No �eseribe: <br />Have ali buitding sewer drain connedions ro the side sewer been identifled and located7 [��s ❑ No <br />Heve all p�operty stortn drainage connections to the sfde sewer been identified and bcaled? �XSs ❑ No <br />Has property heen evalualed for d�a(nage defiaencies with findings communicated to properry owne�'? [a"fes ❑ No <br />Installation Details: , <br />VJhat type and hrand of BWD was installi�d at Uiis sfle (Cban Check BVW,/G�rinder pump, etc.): ��� �`�� ��lL <br />Vdhere was fhe device i�talled (general desaiption, attach. map)7 I 1 IZI � U✓�-�1 — <br />VVas there any othet sewer or storm drdinage wq completed in conjun�tion with the BWD worK? Is so please describe: <br />1 ! �/t{tiD �— <br />Ins4allatian ChecMict: <br />Are all dovmspouts and site drainage diswnnncted from ups6eam oT Ne BWD? es. ❑ No Comments: <br />Does BWD positioning meeb minimum siope requi�ement ot>1%? � es ❑ No Commenfs: <br />Can BYVD be pulled out for Ins�ecUon and ma.intenance aRer loosening thumb screvli [�}'� ❑ No <br />Is BWD locked Into the p�oper posi�on and thumb screw fighlened? �� ❑ No <br />Ci�cle the BWD cnver. imgation cover Qandscape area) fic load bearino ca�(clrive surface) / access hatch (building) <br />Was property uwner shown ths location of Ihe fnstailed BWD7 � � No Comments: <br />Properry Ume�s 5igneWis:fJ���� 2� � Dale: 3-/?-"�S� <br />Insbllers 5ignafure: ������ Date: �T7 �` � �_ - <br />Revislon: 2 1 Friday, Sep[em6er 12; 2014 <br />