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BACKWATER PREVENTION DEVICE FINAL <br />a, INSTALLATION CHECKLIST <br />n�ert ean ��+ . G��s �_ e��, L LG <br />InstaUaHonCompanyNameandConmctlnfo:S�Ct • �1i3,yi�)��-C�5'�j/(�.;�rl� '}` �'.cIO .���?C� <br />Date Badcwater Preventlon device (8WD) was installed� �\ . a ' Oate Ihis fortn was completed �� <br />Insteiletion Propetty Owner �Jame end Contaci Infa t��'Y� �r`�� Yl � ,�rY -(�r�l -7 � <br />Property Address: �L,9 �-� ��c,xL_,At�_ f�t .>P/l F f-6 4 8v� C� I <br />Pre-Incblletion InspecUon C�lecldlet <br />All items must be checked 'Ves' In orde� for a BWD to De consldered for tnshdllaUon <br />Is there e basemenl or level at the house that is at or near essumed sewer main elevetion i�'Yes ❑ No <br />Are there fi�tures In the house iocated belrnv the upstream sewet manhole rim elevation7 �Yes ❑ No <br />is tha side sewer cumently UNPROTECTED ham sew¢r backupe (does not have a BWO fnslalled)7 [�'es ❑ No <br />Site Inspection Chxklist• <br />All items must 6e ahetked 'Ves' Delo�e inspection is conxid�rud wmpfete <br />Was side sewer N Inspected from building to sewer main9 [�Yes ❑ No Conditlon: �i� `'� <br />Daes slde sower Aave at least 1°h slope from 1he bui'�ing to se��er mein7 �Yes ❑ No Oesr.rihe: <br />Have all bulding seurer drain wnnectlons to the side seHer been identifled and located? �Yen ❑ No <br />Have all propeAy stortn drainege conneclions to ihe side aewer heen IdenNfled and tocaled9 (�Yes ❑ No <br />Has property been evalua,. •< `�r drainage defldencies with findings communicated to proparty ownefl (� Yes ❑ No <br />In9tall�tion Detafl4: <br />What rype and brand of BWD was installed at t�la sile (Clean Check BNN, Grinder pum�, etc.): �Hrr{ty' �c_�� <br />Whe�e was the deviee instailed (peneral descriptlon, attash map)? �P. P (�,,�.�(�i:�c��_���,L�i: <br />Was there any other sewer cr storm dreinage worlc wmpieted In njundion with the BWD wak7 Is so piease describe:,_ <br />_ -- ---�C(Yl� <br />Inel�llatlon CAecldist: <br />Are ell downspouts end site drainaga dlsconnected hom upstream oi lhe BWD9 �(] Yes ❑ No Comments; <br />Does BWO positioning meets minlmum alope requirament ot >1°�7 �Xes ❑ �o Comment�: <br />Can BW� be pulled oul for inspection and malntenence after loosening thumb screNR � Yes ❑ No <br />la BWD locked IMo the proper positlon end thumb saew Ilghtened7 [�Yes ❑ No <br />Circ.te the BWD couer rriyalion cove� (fapdscape e�ea) I Vamc load beadng cover (ddve surtaoe) I aocess hatch (huilding) <br />lNas properly owner shovm thloca—li n of fhe installed BWD? ❑ Yes � No Camments: ��nL�_n ��(%�11 <br />1 '. �� �% 5� <br />Property Owners Signature: �`� Dete: ��� � <br />Instelier's Signeture: D�' � ,�—_ <br />Revision: 2 1 Frtday, September 12, 2D34 <br />