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i <br /> ; <br /> BACFM/ATER PREVCNTION DEVICE FINAL ; <br /> ,�,� INSTALLATION CHECKLIST � <br /> � <br /> Installation Company N�me and Conlact Info: `��.- L� ?�� I��u r��� ��r� ; <br /> i r � <br /> Date Back�vater Preventi��n device (BWD)was insfalled:'-��Date(his form was completed: �- �? I S i <br /> Installation Property Owner P;ame and Contact Info:_L-o� � � ���� (�.��� ; <br /> Property Address: ' �'� l-o.M Gx��� �"�. <br /> Pre•Instaliaiion Inspection Checklist: � <br /> �111 items must be checked'Yes'in order for a BWD to be considered(or installation : <br /> Is there a hasement or level of the house that is at or near assumed se�ver main elevation? �Yes ❑ No i <br /> Are there fixtures in ;he house located belovr the upstream setiver manhole rim elevation?[�]Yes ❑No � <br /> Is the side sev�er curently UNFROTECTED from se�,�er backups (does not have a BVJD insta!led)? [�Yes ❑ No ! <br /> Site Inspection Checkllst; , <br /> All items must bs ciiecked'Yes'6efare inspsction is considered complete <br /> Was side sewer N inspected from building to sewer main7 [�]Yes ❑ No CondiNon: —. � <br /> Does side sewer have at least 1°6 slope irom lhe building to sewer mafn7 (Z]Yes ❑ No Describz: ; <br /> Have all building se�ver drain connections to the side sewer been identified and located? m Yes ❑ No � <br /> Hae�e all propetty sto,. 'rainage connections to the side eewer been identified and located7 (�Yes ❑ No � <br /> Has property been evalualed for drainage defciencies v+ilh findings communicated to property owner7 (]7 Yes ❑ No i <br /> Installation Details: „ - <br /> What type and brand of B�VD was installed at this sile( ��an e�k S�er pump,etc.): ; <br /> Where�vas lhe device insfalled(general description,altach map)? Pp�,���Q���:ns P �^ �"U� �^'" � <br /> � <br /> lNas there any other seeier or storm drainage vrork completed in conjunction with the BW�work? Is so please desrnbe:_ � <br /> ��J,_> _ , <br /> i <br /> Installation Checklist: i <br /> Are all downspouts and site drainage dlsconnected from upstream of the BWD? �Yes ❑ No Comments: • <br /> Does B�ND positioning meeLs minimum slops requirement of>1%? [�Yes ❑ No Comments: <br /> Can 84ND be pulled out for inspection and maintenance after loosening thumb screw7 �Yes ❑ No ; <br /> Is BWD locked Into tne proper positlon and thumb screw Ugl,itene���-8 � i <br /> Circle ihe BWD cover. irrigation cover(landscape are�lraffic load bearinq cover fdrive su 1 access hatch(building� i <br /> Was property owner shown lhe localion of the inst�lled BWD7 �Yes ❑ No Comments: ; <br /> � <br /> Property Owners Signature: Date; — i <br /> Installers Signature: � Date:_ ��` � 3 ; <br /> i <br /> Revision:2 ' Friday,September 12,Z014 ; <br /> i <br /> i <br />