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� <br />� <br />BAC�WATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />� ao 6, �( b� �() 93 <br />Date Backv�ater Prevention device (BWD) �vas installetl: �—�^�?I �Date this form was completed: r'i ���als <br />Iristallation Property Ov�ner Naine and Contact Info: (UZl�th -t I<� ��as �l D- p0y� <br />Properly Adtlress: <br />Pre•lnstallation Inspection Checklist: <br />All items must be r,hecked `Yes' in order for a �WD fo Be considered for installation <br />Is there a basement or leve( of lhe house that is at c: near assumed se�.ver main elevation? Yes ❑ No <br />Are ihere fixtures in the house located bzlov�� ihe upstream sewer manh�le rim elevalion7 v Yas ❑ Jo <br />Is the side sewer currenUy UNPROTECTED frem sewer backups (does not have a BWD inslailetl)? �Yes ❑ fJo <br />Site inspection Checkliat: <br />All ifems musf be checked 'Yes' be(ore inspeciion is considered(complete <br />VJas side sewer TV inspected irom building to sewer main? � Yes ❑ No Condition: ,� <br />Does side �ev�er have at leasl 1% slbpe from the tiuiidng to seWer main? � Yes ❑ No Describe: <br />Have all buildiug sev�er tlrain connections to the side sewer heen identified and locatetl? � Ye ❑ No <br />Have ail property storm drainaye connections to tiie sitle sewer been identified and located? �Yes ❑ No <br />Has property been evaluated for drainage deficiencies :^�ilh findings communicated to property ovmer? [� Yes ❑ No <br />Insfallation Details: �—'—or�5� I <br />4Uhat q�pe and brend of BWD v�2s installed at ihis sile Clean Checl BVVU, Grinder pump, etc.): <br />bUnere v.�as the device installed (general descrip(ion, a(taoh map)? �� �� �'•��5� �o� f�f�� �G.�� <br />Was thore any other sewer or storm drainage work completed in wnjunction �vith the BU1�D workl Is so piease doscribe: NO <br />Installation Checklist; <br />Are all downspouts and site drainage disconnected from upstream of tl e BWD? Yes ❑ No Commenis: <br />Does BWD posilioning meets minimum slope requirement of >1%? Yes � No �omments: <br />Can 6WD be pulled out for inspection and maintenance aiter loosening t umb scree�? Yes ❑ No <br />Is BWD locked inlo the proper posilion and lhu cre�v tigMenedT [�Yes � No <br />Circle the B'�VD cover: irrigalion cover andscape are )1lraHic loa bearing cover (drive surface) ! access hatch (building) <br />Was property owner shotvn the location of the inslalled BWD? �Yes ❑ No Commenls: <br />/�O aQ ( / <br />Property Ovmer's Slgn tur Date: � S <br />InstAller's Signafure: �1� _ Date: ��'� � ��d �� <br />Revision: 2 1 Monday, September 15, 2014 <br />