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i <br /> � BACKWATER PREVENT�II�N DEVICE FINAL <br /> � INSTALLATION CHECKLIST <br /> ; <br /> i <br /> Inslalla6on Company Name antl Contact Info: �.�4r�� P� �L!�S ��-V�1�/�5�A?(��jU ( , <br /> Dale Backtivaler Prevention devi�e (81ND)vras installed:�:�ZQ1,�Dal/e�this form�vas compleletl:�,1�./7��rj <br /> Insiallation Property Ovrner Name and Conlact Inio:_����ay�iP, ��ro'f-��o � <br /> Property Address: '�__�_,� 2c'�_�_�'ra� 1�1e <br /> Pre-Installation Inspection Checklist: I <br /> All ifems must be checked 'Yes'in order for a �V✓D to be considered forinstallatron <br /> Is there a basement or Ievel of lhe house thal is at or���ar assumed sewer main ele��alion? es ❑ �b <br /> Are there fxtures in ihe house localed below the upslream sevaer manhole rim elevation? [v� Yes ❑ No <br /> Is lhe side sev�er currently UNPROTECTED from sew�er backups (does not have a 4WD inslalled)? �s ❑ �o <br /> Site Inspection ChecklisL , <br /> FUI ifems must be checked 'Yes'belore inspectron is considerea complete <br /> 1�'as side se�ver N inspecled from building lo sewer main? [V�Yes i❑Nn C r�diiion: <br /> U:;es side sewer have at least 1"b slope irom the building to sewer main? Yes ❑ No D scribe� <br /> Haee all building sewer drain conneclions to ihe side sewer been identified and lo�aled? Yes No <br /> Have all property storm drainage connections lo the side sewer been identified and located? Yes ❑ NQ� <br /> Has property been e��aluated for drainage deficiencies with findings cr�mmunicated (o property oe•aner? [�Yes ❑ No <br /> Installation Details: I <br /> bUhat q�pe and brand o(Bu1�D was installed at lhis site (Clean Check BI�N,Grinder pump, etc.):��,,,�k' <br /> b'Jiiere�vas ihe devir,e installed (general description, aifacl� mapj? e rt�' va,r� Aloc�-(�t (.��s ���,�.— <br /> bVas there any other se�ver or storm drainage work completed in conjunction �vith the BWD work? Is so please describe: 1� O <br /> Installation Checklist: <br /> Are all downspouts and sile drainage disconnected from upsUeam of lhe Bti ? ��s ❑ No Comments: <br /> Do��s BWD positioniny meets minimum slope requirement of>1%? i es ❑ No Co�n}N�nts:_ <br /> Can BWD be pulled out(or inspeclion and maintenance a(ter loosening ihumb scre�v? (]Yes <br /> ❑ IJo <br /> Is E3WD locked into Ihe proUcr pqsition and thumb screw tighlened? [�s ❑ no <br /> Circle ihe BWD cover�rcige(ie�ue�er �ndseape area)1 iraffie load�b e�i c�y cover(drive surface)I access hatch(building) <br /> l�,�as properiy ovaner shown the location of the installed BNlD? []'Y e s �❑ No Comments: <br /> , ��, �,,/I <br /> Property Owner s Signaluie: �• l��!'" �-� '�;/!?� (Dale �/3`��S <br /> � <br /> Installer's Signature:������� .ay�— Dale���3�?.�15 -- <br /> Rewsion: 2 1 � Monday, September 15, 201A <br />