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- I <br /> � <br /> BACKWA`TER PF�EVENTI09V DEVICE FINAL ; <br /> � <br /> lNSTALLATION CFiECKLIST � <br /> ' <br /> " i <br /> � n ! <br /> Insfallalior Company Name and Confact Inio: ���1 Pri�LL'S t•L V�11 r��I�a . �ti� • ; <br /> Dale Backwaler Prevenlion device(E3WD)was inslalled:_�}-q-�S Dale this form was wmpleted: �1 '� i <br /> Instailalion Property Owner Name and Contact Info: k�� �^ � �lo�W Gv�q `: <br /> � <br /> PropertyP.ddress: \�?,O�l [�E-L�-R" PcvE F✓f�r' !/�-'�' ���G1�'� — i <br /> Pre-Installation Inspection Checklist: � <br /> All rlems must be checked'Yes'in order(or e BWD to 6e considered for insfallafion � <br /> Is Ihere a b;�sement or level of the house that is at or near assumed sewer main elevaGon7 �y�res ❑No ` <br /> Are there fixtures in Iha nouse loc3ted below the upstream sewer manhole rim elevation?� ❑No i <br /> Is the side sewer curten'ly UNPROTECTED from sewer backups(does not have a BWD installed)7 _ es ❑No ; <br /> i <br /> Site Inspection Cheokllst: � <br /> Afl�lems musl be checked'Yes'be(ore�;ispecfion is cansiderad�lefe ; <br /> Was side se�ver N inspected f•om bullding ro sewer main? es ❑No Condition: �n.�s:9 _ � <br /> Qoes side sewer have at leasl 190 slope lrom the buiiding to sewer main7 Q� ❑ No Describe: � <br /> Have all building sewer drain connections to Ihe side sewer been identified and located? �"�es ❑ No � <br /> tiave all p�opeRy storm drainace connections to Ihe side sewer been identified and located? [t�e's ❑No ! <br /> Has property been evalualed for drainage de4ciencies w�ilh findings communiqted I�property o�vner7 e� ❑ No <br /> ; <br /> Installation Datails: � <br /> lhmat type and brand of BWD was installed at this sile lean Ch c�BWV,Grinder pump,etc.): ' <br /> i <br /> Where eras the device inslalled (goneral descnption,attach map)9 W�++-o A"�'TAerFE�'� � <br /> � <br /> Was ihcre any other sev�er or slorm drainage work mmpleted in conjunclion with ihe BWD work7 Is so pleasa des�ribeNG � <br /> � <br /> � <br /> ------- ' <br /> Installation Checklist: ; <br /> Are ali do�mspouts and sila dreinage disconnecled from�pstream of ihe B�ND1 es ❑No Commenis: � <br /> Does BN'0 positioning meels minimum slope requirement ot>1°/,? [ es r� No Comments: � <br /> Can 81ND be pulled out ior inspectlon and rnainlenance after loosening thumb screw9 Yes ❑No ! <br /> Is BWD lo�ked inlo ihe proper position and thumb screw tightened7 'es ❑ No <br /> Circle the BWD cover:irrigation cover(landsrape area) raKc foad ann cover drive surface ac�ess halch(building) � <br /> Was property owner shown the location of fhe installed BWD7 es ❑ No Ccmmenls: ; <br /> Properiy Uvmers Signature: �%�-s'In�-�M�- Date: $� ��� _� ! <br /> Inslalir.rs Signalure: Date: _�— 1'��r ; <br /> Revisiom 2 1 Mnnday,September 15, 20i4 ' <br /> 1 <br />