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BA�KWATER PREVENTION DEVICE FINAL <br /> � Ey INSTALLATlON CHECKLIST <br /> � <br /> Inslallaticn Company Name and Contac� Info: _�,,�ri� P��L��S �(..��+'�/�S i� IG� f�; ( <br /> Date Backvdater Prevenlion device(BWD)was instailed: �7JLY��15 Dale th�is form was completed:�5 <br /> Inslallation Property Owner Name and Contact Info: 1�v,r�e ' 1,^ef�ev� 4252SZ-3y�J3 <br /> Property Address:�51\ l�-r�txrrcl �1.re , E��P rc E G✓A 9F11�/ <br /> Pre-Installation Inspection Checklist: <br /> Alf ifems musl be checked'Yes'in order for a 8WD to be considered for installation <br /> Is Ihere a basement or level of the house that is at or near assumed se�ver main elevation? �es ❑ �b <br /> Are there fix(ures in;ihe house localed below the upslream sewer manhole rim elevafion7 ' Yes ❑ No <br /> Is the sitle sewer currently UNPROTECTED (rom sewer backups (does noI have a 6WD installed)? [�es ❑ No <br /> Site Inspection CliecklisL• <br /> A11 ifems musf 6e checked'Ves'be%re inspection is considered copiplefe <br /> INas side sev�er N,inspected from building to sewer main? L�Yes ❑ No Contlilion; C��v� <br /> Does side sewer have at least 1% slope from Ihe builtling to sewer main? [�j Yes ❑ No Descrihe: <br /> Have all bui�ding sewer drain conneclions to the side sewer been identi(ied and located? [✓j'�es ❑ No <br /> Have ail property storm drainage conner.(ions fo the side se�ver been identified and located? �'es ❑ No <br /> Has property been evaluated for drainage deficiencies tvith findings communicated to properiy owner7 �es ❑ tJo <br /> Installation Detaiist <br /> UVhat type and brari,d of f3WD was installed at Ihis site(Clean Check aWV, Grinder pump, elc.): _�c,,., C.,�.��� <br /> l��lhere was ihe devlc�inst�dled (general description, attar.h map)? _ 4l/��P G�'-'lTP<LL� <br /> Nlas ihere any other sewer or storrn draina,ye work compieled in wnjunclion with the DWD work? Is so please describr:'�U <br /> Installaiion Checklist: <br /> �rr, all do�vnspouls antl site tlrainage disconnecled (rom upstrea��n o(the B�WD7 Yes ❑ No Comments: <br /> Docs BWD p�si(ionjng meets minimum slope requirement o�>1%? ���Yes ❑ No Coi en�s: <br /> Can �WD be pulled qut for inspection and maimenance atter looseninq Ihumb.screva? Yes ❑ No <br /> Is FiWD lor,ked info the proper position and ihumh screw fightened? _ es ❑ No <br /> Cirr.le fhe BWD cover. ir�i,q��an.co'�ver andscape area)1 traffic loatl bearing cover(drive sur(ace)I access hatch (building) <br /> VJas properly owner shown ihe localion o(lhe installed(3WD? �S ❑ No Comments: <br /> Property Owner's Si.gnalure � '�/ �„ <br /> ._ — ____ —__/-�.—__.___— �d1C:—� � � _ �j`� .__. <br /> Inslall�r's Signature�____ - _ Da�e: �1 71fJ�1,�� <br /> �'` �-------- — <br /> Rr��ision: 2 1 fvtonday, Sr_ptember 15, 207.1 <br />