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BACK1!'�ATER �'REVENTION DEVICE FiNAL <br /> 1NSTALLA710N CHE�:C{LIST <br /> Instailation Company Name znd Contact Info: � ��o//� Y�/�r/��3�r��' <br /> Daie Backv+aler Prevenhcn device(BWD)eras ir,stalled: �//iG/i S' Daie this forrr��ras como!eted: � /� i-� <br /> Installation Prop=�ty Owner Name and Cont�cl Inio:�o/c,�/�iJ i���c'� <br /> Pro,�er�y Nddress: / 2�'— G' � — — <br /> Pre•Installation inspection Checkiist: <br /> lifl items musl be chedted'Yes'in order ior a BV✓D to be consider�d forinstallafion <br /> Is there a hasement or i:vel of the house that is at or near assumed se�ver main elevation?�Yes ❑No <br /> kre tnere fr�ures in the house loczted bzlovl the upstrzam se�vzr manhole rim elevation?�j Yes ❑ No <br /> Is the side se�•der currently UNPP.OTECT ED from see�er backups (do�s not have a BWD Inslalletl)1�Yes ❑ No <br /> 5ite Inspectlon Checklist: <br /> P.!I items must be che�ked`Yes'6e�ore inspection is consiaereo compfete <br /> Vti'as side sevaer N inspected from building to se��ver main? �]Yes ❑ No Contlition: — � <br /> Does side se�ver have at least 1°6 slope from the building to sev�er mainl �Yes ❑No Describe: _ <br /> Have all building sewar drain connections to ihe side se���er heen Identifed and located? �Yes ❑No <br /> Have all property storm drainage connections to the s(de se��rer been id�ntified and located? [�'es ❑ No <br /> Has property been evaluatetl inr d2inage deficiencies�vilh fndings communi�ted io properly owner7 (�Yes ❑ No <br /> Instailation Details: <br /> �,h'hat rype and brand of 614�D was installed at this site(C�-�1�eckB�lri /? Grinder pump,etc J: <br /> tVhere was the device installed(general description,attsc ap)? S 'OP a� hoc+SG �'� i3O1�� ���%:!1� <br /> ��,/G c oir�e/� — <br /> ;��as ihere any other se�ver or storm drainage t,�ork completed in wnjunction tvith lhe BWD viork?Is so please descroe:_ <br /> �� <br /> installatlon Checklist: <br /> Are all dov+nspouts and sile drainage disconnected from upstream of the BWD? [�Yes ❑No Cor��nents: <br /> Does BWD positioning meels minfmum slope requirementoi>t°�o7 ,�Yes ❑Nu Com^�::nis:_ <br /> Can BN'J be pulled out tor inspection and maintenance after loosening thumb screv�? [�Yes ❑ No <br /> Is B�ND lor,ked into the pro er�ositio �!th�mY-sereer-��)ened7 �J]Yes ❑ No <br /> Circ!e the 5WD co�; r, irrig37on cover(IaPd�cape-�reaj�lVaffic load beanng cover(drive surface)I acass hatch(building) <br /> VJas properry owner shown the location of lhe,.�slalied BWD� yQ Yes ❑ No Comments: <br /> Froperty Own�:�s Signature /C//� � Date: J �S <br /> Inst=llers Slgnatur . —- Dafe:��3 �� <br /> Revislon: 2 1 Friday,Sep[ember 12,2014 <br />