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� <br />� <br />BA�Ch'WATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Instailafion Company Name and Conla;l Info: �� <br />Gate Backvaater Prevention device (BN�D) was inst� <br />InslaYallon Prope��y Owrier Naine and Contacl Info� <br />Property Address: __ � Sa � ry. <br />F're•Installation Inspection Checklist: <br />Oale this form was completed: �2(n -I S <br />All ifems rnusf be checked'Ves' in ord�r for a BWD to be r.onsrdered lor instaifation <br />Is there a basemeni or leve! of the house that is at or near assumed se�ver main elevation? � Yes ❑ No <br />Are there fxlures in Ina house lor.afed below the upstream sewer manhole rim elevation? Yes ❑ <br />Is Ihe side sewer currenlly UIJPROTECTED from sewer backups (does not have a BWD inslalled)? ,.f Yes ❑ No <br />5ite Inspection Checklist: <br />lill items musl bo checked'Yes' before inspection is considered co plefe <br />Was side sewer 1V inspec(ed from builtling b sewer main? Yes ❑ No fidilion: <br />Does sidc sewer have af Ieast 1"/o slope from Ihe building lo se�ver maln? Yos ❑ No �escribe: _ <br />Have all huilding sewer drain conneelions lo ihe side sewer been identifed and localed? � Yes ] No <br />Have all property slorm drainayo conner,lions lo Ihe sitle sewer been identified and localed? Yes ❑ N <br />Has proper(y been evalualed for drainage deficiencies vaith findings communicated fo proper�y owner7 Yes ❑ No <br />Installation �etails; <br />1't4iat type ancl hrand o(13WD was installed a� ihis sile (Clean Check IiWV, Grinder pump, etr,.): __�2�tn �� <br />Wherr, was Ihe d����i;:r, installeC (gereral descriplion, aftar,h map)? cy-reh �� a� ��. ho,� F(n'_�'pN,,.___ <br />�''��-�'-� t'�--------- -- -- <br />W;u; tlif�re s�ny olher sr�v�r,r o� slorm drain�ge work r.ompieled in conjunction with ihe [3WD woik9 Is so please describe. r,/0 <br />Inslallation ChecklisC — <br />A;c all dov;nsFouis and site tlrainage disconner,led from upsiream of ihe B D? .(-] Yes No Commenis: �}oF� G�-p <br />Unes t�wo posi����ning mee�s minimum slopc requiremem of >1�5? [ Yes ❑ No Com �enls: <br />C�n IiVJD be pullr,d out (or inspecfion and malntenancr. altef loosening Ihu�nb screw7 Yes ❑ No <br />Is RWU Incked inin the propor posifion and Ihumb screw tighlened? �Yes ❑ No <br />Cirr.lr. Ihe BWD awer: ini�r t�ti�a��a o a��r�c�� ring covr,r (drive surface) I accoss halch (building) <br />UJ;�s propr.rly i�vmer showii Iho location of ihe inslalled DN/D? L es [] No CommeNs: <br />Propeity Owner's 5ignat���e: _--�_ .��`- '�_�`_._ <Dafc� _ 0�6 -2�,f <br />Inslaller'sSignafure:_���,,,v� �/o/ <br />�!k�d-�- ` Uale: ��z�� 1J <br />��L'VI51011: % . �'----' <br />A4nnday, Scptember 75, 2ptq <br />