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BACKWATER PRi VENTION DEVICE FIR+AL <br /> INSTALLr'�TION CHEGKLIST <br /> Inst�llation Company�Jame and Conlacl Inio: �/�oilo !�/i � l3�� 9 �`�=5) 3�5�' �s�� <br /> � I/ 3/, � <br /> Date Back�va�er Prevention device(B4�D)was installed: / 2� /> Date this(orm was completed: ?. <br /> Installation Property Oe+ner Name and Contact Info: �leT��n V�'��G e"�� <br /> Property Address: /�/3/ /o�ll� �n A''� ��/z s� �s�— 3�s�7 <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order kr a BWD to be considered!or installation <br /> Is there a basement or level of lhe house that is at or near assumed sev�er main elevation?,�.�,�les ❑ No <br /> Are there fixtures in the house Ic�ated belo�.v the upstream sewer manhofe rirn elevation?Ui res ❑ No <br /> Is ihe s�de sewer currentiy UNPROTECTED trom sewer backups (does not have a BWD installed)?0 Yes ❑No <br /> Site Inspection Checklist: <br /> All items musf 6e checked'Yes'6elore nspection is considered complefe <br /> Was side sewer N inspecled from building to see�er main? [�Yes ❑N�o ondilion: <br /> Does side sewer have at least 1%slope(rom the buiiding to se:�er main? L�J Yes ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and localed? �Yes � No <br /> Have all properry storm drainage connections to the side sewerbeen idenlifed and localed? �Yes ❑ Nq� <br /> Has properh,r been evaluated for drainage deficienc!es with f ndings communicated to property oeme�? LJ Yes ❑ No <br /> Installation Details: <br /> NJhat type and brand of BWD was installed at this(�le(CI,an Check B rinder pump,elc.):_ <br /> Where�vas the device inslalled (general descripliolr,attach-�j? r/c n r q �'i �i7 <br /> �Vas there any olher sewer or storm drainage work completed in conjunclion with the BWD work? Is so please describe:_ <br /> �j/C% <br /> Installalion Checklist: � <br /> Are all do;mspouls and sile drainage disconnected from upsiream o(Ihe BWD? �Yes ❑ No Comments: <br /> Dces BWD positioning meets minimum slope requirement o(>1%? ��'es ❑ No C rtiments: <br /> Can BWD be pulied oul tor inspeclion and maintenance after loosening�humb screw? �Yes ❑No <br /> / <br /> Is BWD locked into the proper posilion snd lhumb screw lightened? �Yes ❑ No <br /> Circle the BWD cover. irriga�on cover(landscape area)1 traffic lo�ad,�b anng cover(drive surface)/access hatch (building) <br /> Was property owner sliown the location oF the installed B�VD? I.�'1'es ❑ No Commenls: <br /> Property0wnersSignature., ' � � r, � _ Date: i/Z���-5 <br /> Installers Signatuc� - ` Date: ���i/i� <br /> Revisian:2 1 Friday,September 12, 2014 <br />