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� <br /> BACKW�4TER PREVENTION DEVIGE FINAL <br /> � INSTALLATION CHECKLIST <br /> Installation Comaany Name and Contact Inio:�ri//� /�/u� R�.+y ��/zl� 387 /S� 7 <br /> Date Baclnvater Prevention device(BWD}was installed: ��/2G�/�/ Date this form was completed: i z Ly i� <br /> idG:val D ��/p n/G <br /> Installation Property Owner Name snd Contact Info:� ��izS� _s i L — S3/% <br /> PropertyAddress: ?_��� r��r�/G s> `���ei� �fszc/ <br /> Pre•Installation inspection Checklisl: <br /> A�I ifems must h: checked'Yes'in order fora BWD fo be considered forinstallafion <br /> Is there a basemenl or level o(fhe house ihat is at or near assumed sewer main elevalion? �Yes ❑N� <br /> Are ihere fxtures in the house Iccaled heloa the upstream sawer manhole rim elevation?�Yes ❑No <br /> Is ihe side sewer currently UNPROTECTED from sewer backups(does nol have a BWD inslalled)?�Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must 6e checked'Yes'be/ore inspection i;:considered complete <br /> Was side sewer TV inspected from building to sewer main? �/ Yes ❑ No Condilion: _ <br /> Does side sewer have at least 1% slope(rom the building lo sewer main? ��Yes ❑No D�-scribe: _ <br /> Have all building se�ver drain conneclions lo Ihe side sewer been i�entified and loca�ed? �(]/ Yes ❑No <br /> Have all property storm drainage conneclions to Ihe side sewer been identified and located?�Yes ❑No <br /> Nas property been evafuated for drainage detciencies with findings communicated to property o��mer'l p Yc•s ❑ No <br /> !nstallation Details: <br /> What type and brand of BWD was instslled at this ' ean Check�der pump,etc.): <br /> Where was lhe device installed(general description,attach map)? t �=�� � �n i2�c tit o��' .,,�a ve/ <br /> 0 0 <br /> wu/h '+/4y !/� #'G�l1. /t/j �'r/I'IC� <br /> Was there any other sewer or stom�drainage work completed in conjunction with the BWD�vork?Is so please describe:_ <br /> Installation Checklist: <br /> Are all downspouls and sile drainage.�isconnected (rom upsiream of the BWD7 [�Yes ❑No Comments: <br /> Does BWD positioning meels minimum s!ope requiremenl of>1%a?�Yes ❑No Comments: <br /> Can BWD be pulled oul for inspeclion and maintenance after loosening thumb screw? ,�Yes ❑No <br /> Is dWD locked into the proper posilion ard thumb screw lightened?�/j�'es ❑ No <br /> �— <br /> Circle the BW�cov : ga ion cov_ er(I�caoGaFea 1'raific load bearing cover(drive sur(ace)1 access hatch(building) <br /> Was propert� owner shown ihe localion ot lhe inslalied BWD? (�'Yes ❑No Comments: <br /> Property0vmer'sSignature: �.�.�� �Aa�f Date: /�./2l/ec/% <br /> Installer's Signatur �---- Date: 12�26�Z���_ <br /> Revision: 2 1 Friday,September 12, 2074 <br />