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�/�C�IUA�'ER P6�IEV�fVTIOfV ��VICE FI(VA►L <br />siV�i.�LL.AilOf� �d��CFCLIST <br />Instaliation Company Name and Contact Info: M u�-� I���n r� i�� +t <br />1 =7�U—�3�c <br />Dale Backwaler Prevenlion device (BWD) was insialled: r� ���� Date Ihi� form was cnmpieted• S' 2 d'�!� <br />Installation Properiy Owner �ame and Contact info: K� �i �- y �� �C/ �-j 2 j� `(� �(�7/( <br />Property Address: �� �f�Z� Z <br />Pre•Installation Inspection Checklist; <br />AI! items musl be checked'Yes' in order for a BWD to be consldered for instalfation <br />Is th�re a basement or level of th, house that is at or near essumed se���er main elevalion? [� Yes ❑ Wo <br />Are there tixtores in the house locat�d below Ihe upslream setver manhole rim elevation? � Yes ❑ No <br />Is the side sewer currently UNPROTE:.?ED irom sewer backups (does not have a BWD inslalled)? �j Yes ❑ No <br />Site Inspection Checklist: <br />AI! i(ems must be checked'Yes' before inspection is considered complete <br />14�as side se:ver N inspected irom buiiding to se�:�er mainl (� Yes ❑ No Condition: � onvY,�t ��.,y�y�L� <br />Does side sewer have at least 1% slope irom the building lo sew�er main9 L7jc Yes ❑ No Describe: <br />Have all building sewer drain connections to the side se�ver been identi(ied and localed9 (� Yes ❑ IJo <br />Have ail property slorm drainage conneGions to �he side sevaer been idenlified and localed7 � Yes ❑ No <br />Has property been evaluated for drainage deticiencies v+ith findings communicated to property owner? �Yes ❑ tJo <br />Installatian Details: <br />Y�ihat iype and t�rand of BWD vras inslalled at this site (Clean Check BWV, Grinder pump, etc.): I'�� �4 �4 ��(�c� <br />Where was the tlevice installed (generai descriphon, atiach mapJ? � sc�• 6 w- �-r c�h � <br />V�las there any ofher se��rer or storm drainage work compleled in conjunction vnlh lhe PWD vrork? Is so pleas6 descdbe: _ <br />Insfallation Checklisf: <br />lu�a all downspo�ts and site drainage disconnecled from upstream of ihe �WD? � Yes ❑ hJo Comments: ____ <br />Uoes BW� posifioning meets minimum slope requirement of >1%7 �j Yes j] Ido Comments: <br />Can BVJD be pulled ouf for inspection and maintenance afler loosening lhumb screv�l �X�u <br />Is BWD locked into the proper posilion and Ihumb screv� tighienea�Yss-f] IJo <br />Circie ihe BWD cover. irrigalion cover (landscape area) l lraffic bad bearing cooer (drive surtace)1 acr,ess hatch (building) /U�/�- <br />Was property o.vner shcean lhe focaGon of the inslalled BWD? ,�Yes ❑ Wo Commenis: ___ <br />Property O�vnefs Signature: Uate: _ <br />Insfaller'sSign3lure:. /��---- Dafe: S'�S'�f <br />Revision� 2 1 Mcnday, Septemher ] 5, 201�1 <br />