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� <br />BACK�JVATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Inslallation Company Name and Contact Inio: �ts r� (( o.,sn-w. � r, oN La..c - Cuz r> 7�1 - 3�r�o <br />Dale Backe�ater Prevention device (BWD) vlas installed: � ap�. I Zo�S' Date this form was completed: 1 �tp�J Io� i <br />Installation Property Owner Name and Conlact Info: Cl.a. �r S+(',a,.,Mr.. �,:��' %� -_� <br />PropertyAddress ��`�� �C����tiz� Da_ (_v� rz� tr �,J�� �f �7�u ( <br />Pre-Installation Inspeciion Checklist: <br />FlA i!erns musf be c��ecked'Yes' m oider (or a BIND f� be considered lor installation <br />Is there a basemen: or level of Ihe house ihat is af or near assumed sewer main elevation? � Yes ❑ No <br />Are there fixlures in the house located balow the upslream se�rrer manhole rim elevalicn? � Yes ❑ No <br />Is the side se�ver curreniiy UNPROTECTED trom sev+er backups (does not have a BWD instailed)? � Yes ❑ Plo <br />Site Inspection Checklist: <br />A!I items must be checked'Yes' belore inspecfion is conside�ed complete <br />Was side sev:er iV inspecfed irom building lo se�ver main? � Yes ❑ No Cor,dilicn. _ <br />Does side sev�er have al least 1°i6 slope irom the building to sewer main? [}� Yes ❑ No Describe: __ <br />Have all building see�er drain connections to the side sev.�er been identified and localed? [�"Yes ❑ No <br />Have all properly slorm drzinage connections to the side sewer been identifed and localed? [�] Yes ❑ No <br />Has properly been evalualed for drainage deficien�ies with findings communicated lo property oemer7 � Yes ❑ No <br />Installation Details: <br />What type and brand of BWD �vas installed at this site (Clean Check BUN/, Grinder pump, elc.): C14.a�� Q��C(,�C �, W�) <br />lNhere was the device installed (general descriplion, attach map)? Wc s r S� nr� o� /�a�: r� <br />N�as there any oth�r sewer or storm drainage tvork completed�cqnjunction viith the [3N'G �vork7 Is so please describe: <br />,Q� ���rf,�llv�0 C�(vc�,, ,n.F C�o � lt�JVl, SrYPr�.•1 rr1 �L✓/i <br />Installation Checklist: <br />Are all do�t�nspouts and site drainage discor�nected trom upslream of the BIND? Yes ❑ No Cominenls: <br />Does BWD positioning meets miniinum slope requirement ot >1%7 �Yes [ No Comments: <br />Can BWD be pulled out (or inspecfion and rnainlenance after loosening lhumb screw? [�j Yes ❑ No <br />Is BWD locked inlo lhe pro erposition and Ihumb screw tighlened7 [� Yes ❑ No <br />Circle lhe 8WD covec irrigalion cove�andscape area) / traffic load bearing cover (tlrive surface) /'access hateh (build�ng) <br />Was property owner sho�vn lhe localion of the inslalled BWD7 �Yes ❑ No Commenls. <br />p���,1�� i <br />Property O�vner's Signature: --�:'�-'-"� . cr Date: �/- i-/ S <br />Inslaller's Signalure: Q+2_ �' '' Date: 0? r��� �. /S' <br />� <br />Revision: 7 _ Fridzy, SepternLer 77, 201d <br />