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BACKWATER PREVENTION DEVICE FINAL <br /> fNSTALLATION CHECKLIST <br /> Installation Campany Name and Contact Irfo' /�r�/�i /�hcn�r <br /> Date Ba�kwater Prevenlion device(BWD)was installed: ?/�3//S _Dale this form was completed: .�//3//.� <br /> installation Property Owner Name and Contacl Info:� / l3f:in No�oi <br /> Property Address: Z/0 7 �-.%�l+�C <br /> Pre•Installation Inspectian Checklist: <br /> All items must 6e checked'Yes'in order tor a BWD to be considered for insfallaG'on <br /> Is there a basement or level of the house that is at or near assumed se�ver main elevation?[�Yes ❑No <br /> Are there fixtures in lhe house located beloa:the upstream sewer manhofe rim eievation?�]Yes ❑ No <br /> Is the side sewer cunenUy UNPROTEC7ED from se�ver backups(does not have a BNlD installed)?�Yes ❑ No <br /> Site Inspection Checklist: <br /> All ifems must be checked'Yes'be(ore inspection is considered complete <br /> Nlas side sewer N inspected from huilding to sev+er main7 �Yes ❑ No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main7 [�'es ❑No Describe: <br /> Have all buiiding sewer drain connections to the side sewer been identified and Iecated7 �Jfes ❑ No <br /> Have all property storm drainage connec6ons to Ihe side se�ver been identifed and located?�[�Yes ❑No <br /> / <br /> Has property heen evalualed ior drainage deficiencies wilh fndings communicated to property owne(1 �Yes ❑No I <br /> Installation Details: <br /> What type and hrand of BWD was inslalled at this sit Iean Check ,Grinder pump,elc.): <br /> Where was ihe device installed (general description,attach map)? r„ n...�� o�ew, Sn Fi�..�•� C F <br /> J .o iZ <br /> �Vas there any other sewer or storm drainage work compieted in conjuncticn wilh the BWD wark?Is so please describe:_ <br /> N� <br /> Installation Checklist: <br /> Are all do�vnspouls and site drainage disconnecled from upsiream o(the BWD? �Yes ❑ No Commenis: <br /> Does BWD posiGoning meets minimum slope requiremenl af>1°h7 �Yes ❑ No Commenis: <br /> Can BWD be puiled out(or inspecfion and mainlenance after loosening ihumb scre�v? [�Yes ❑No <br /> is BWD locked into the proper position and lhumb screw tightened9 Q Yes ❑No <br /> Circle Ihe 8WD cover: irrigation cover(landseape area)I lr oad bearing cover drixe�u I access hatch (building) <br /> Was property owner shown ihe locai��r of e installed BWD7 Yes ❑No Comments' <br /> i ,� <br /> � Property Owners Signalur // ' �' •-' ��✓ ' Dale: 3�9/iS <br /> InstaUels Signalur _ Date: 3���.� <br /> Revision: 2 1 Friday,September 12,2014 <br /> / <br />