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BACKWATER PREVENTION DEVICE FINAL <br />E„ INSTAL.LATION CHECKLIST <br />�ri cc�r� ���Yi G- � s�de �>�� f�, L Lc_ <br />instaila�ion Company Name and Con(aCt Inio:3� �r ,�' /v j,ii� "��S�iI ��rY'Jc �:�G �) �/10 o7CJ K�� <br />Date Backn�ater Prevention dev;ce (BWD) �•+as installed:� . Date this form rras completetl: � � I\ <br />Installation Property Owner Name and Contact Into: __�J_'a �=31L� _ <br />� <br />Property Address: n1� I I �l''te {�1�� �i%__ X�_ ��)t'� P --�=-��3�� � - <br />Pre•Installation Inspection Checklist: <br />All items must be checked 'Ves' in order (or a BWD to he r.onsidered for installation <br />Is there a basement or level of ine house ihal is at or near assumed se�ver main eievation? �f Yes [J \o <br />Are there fixtures in the house located be!oti:� Ihe upslream se�ver manhole rim elevafon? �.Yes ❑ No <br />Is the side sea�er currently U�UPROTECTED irr,m sev:ar bzckups (does not have a BIND installe:i)? �1'es ❑ No <br />Site Inspection Checklist: <br />All ifems must be checked'Ves' 6efore inspection is considered comp!ete <br />1Vas side se�r;er TV ��spectetl irom buildina lo see�er main? l� Yes ❑ Ido Cundition: ._ �C`�c�____ _ <br />Does side see�er have at least 1% slo�e (rom the buiiding to sevrer main? � Yes L; No D.scribe: _ <br />Have all building see�er drain connecl.ons to the side sei•rer been identif�ed and localed? [� Yes ❑ No <br />' iave all property srorm drainage con�ections to ihe sitle sewer been identified and localed? �Yes ❑ No <br />Has propery been evaluated for drainage deficiencies �vith findings comr�unicated to property oemer? �j Yes ��1 No <br />Installation Detaiis: <br />1�}lhat type and brantl of BVdD was inslalled at Ihis sile (Clean Check BWV, Grinder pump, e;c.): ��_,Sf'�, i� <br />1Nhera �vas the dewce installed (generat description, attach map)? .�_'L�__( �L�'-LtPC(__ ! 7,S_ y�.��(_r <br />4Vas there any other se�ver or slonn drainage a�ork <br />in conjunciion r�ith Ihe DWD e:orh? Is so please describe: _ <br />Installacion Checklist: <br />Are all downspouts and site drainage disconnected irom upstream of the f3VJD? � Yes ❑ No Comments <br />Does BWD posilioning meels minimum slope requirement of >1907 �Yes �__j No Comments: _____ <br />Can BWD be pulie� out tor inspection and mainfenance after loosening Ihumb scre�v? �j Yes ❑ No <br />Is DLN� locked into the pr�pr.r �osition and thumb scre�v tight�ned? �Yes ❑ No <br />Circle the BWD cove�rrigal� cover�landscape area) I traflic load hearing c:over (drive suface) I access hatch (buddingj <br />Was properiy o�vner shovm the location.ci lhe installed BWD"? �Yes ❑ No Comments: <br />Properiy Owner's <br />Installer's Signaiure: <br />Revision: 2 <br />� <br />Date: 1 oL / <br />D2te: I a <br />Friday, Seplember 12, 2C14 <br />