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BAC6CWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />�ri can <br />Installation Comp2ny Name and Contaci Info:J��i <br />Date Backvlaler Prevention device ;BWD) eras insta <br />Installalior Property O�vner Name and Contact Info: <br />i <br />PropertyAddress: �l�a �3d�/�� <br />� <br />c. <br />Date ihis form was <br />Pre-Installation Inspection Checklist: <br />Ail items must be checked 'Ves' in order for a BWD to 6e considered (or installation <br />Is there a basement or level of thz house ihat is at or near assumed se�ver main elevation? � Yes ❑ No <br />Rre there fiztures in ihe house loca!?d below the upsiream sewer manhoie rim elevation? � Yes ❑ No <br />'L <br />r <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? �Yes ❑ No <br />Site Inspection Checklist: <br />l�ll items must be checked'Yes' be%re inspecfion is considered complete <br />Was side sewer N inspecled frnm building to sewer main? [�] Yes ❑ No Conditiun. __��___ <br />Does side sewer have at least 1% slope from ihe huiloing to sevrer main? �j Yes ❑ No Describe: <br />Have ail building sewer drain connections ic the side sewer been Identified and :ocatedl [�Yes ❑ No <br />Have all property storm drainaye connections to the side sewer been idenlified and lo�ated? [�Yes ❑ No <br />Has property been evaluated for drainage deficien�ies with findings communicated to prooerty owner? �'Yes ❑ No <br />installation Details: C <br />What type and brand of B�ND �vas installed at this site (Clean Check BWV, Gnnder purnp, etc.): . cx'_�_ <br />1�Jh.ere was ihe device inslalled (general descripfion, atiach map)? �(' /X .`E-' p�/�' DlP�i—�.._.�GL�� <br />I��as there any other sewer or storm drainage work complPted in conjunction with the EiVVD �vork7 Is so p!ease descnbe: _ <br />--- -- — ��-'-� �{�-- <br />Instailation Checklist: <br />Are all dovmspouls and sitc drair�age disconneeted irom upsiream u( ihe BVJD? �Yes ❑ No Comments: <br />Does BWD posilioning meets minimum slope requirement of >1°/a? [`�( Yes ❑ No Comments: __ <br />Can BWD be pulled out for inspeclion and maintenance after loosening lhumb screv�7 [�'Yes ❑ No <br />Is BWD locked into the per posilion and thumb screw lightened? [�1'es ❑ No <br />Circie Uie BWD cover irrigaGon cover.(la � scape area) I iraffic load bearing c:over (drive surface) I access halch (building) <br />lNas property owner shown the localion of the��talied BWD'? �Yes ❑ No CommenLS: <br />�roperty Owner's Sic <br />Installer's Signalure: <br />Rc��ision: 2 <br />Da1e: �5 <br />Date _ �___, <br />Friday, September 12, 2014 <br />�4_ <br />