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E[� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />'nslalla6cn Company Name and Contact In`o� <br />Da.(e 42cke;ater Prevention device (BVdD) �vas installed: �a �1� �, _ Date this form tivas completed �5� �=; <br />i s;a lation Property O�vner Plame ard Contact In(o: ���r,_ /��,,�� <br />Poeer,vAdaress. ?y�2� C�,�r� Av__e ��zf<•:'l-l- l,�R ��`SZUI <br />Pre•Installation Inspection Checkiist� <br />�� �! �larns aws± te chec�:ea 'Yes'rn order ior a 814�D to be cons;dereo for instal!ation <br />s h�ere a basemenf or !r;vel of the house Ihat is at or near assumed se�ver ma�n e!evation? ��Yes �] No <br />��,re (here 6xfwes in Ihe nouse localed 6elow 1ne upstre2m sewer manhole rim elevation? [(�j Yes ❑ No <br />k the side sew�r wrrently U•!PROTECTtD i.om sea;er backups ;docs not have a BVd� instailetlj" [-�l�'es ❑ No <br />Site i�.spection Checklist: <br />.il; ;,n,n5 ITI/Si OB Ci�?Cn?Q 'YES� OC�OlB 171SDFCtion is consideieG comple(e <br />':'das side sewer N inspected from building to sevrer main? [y�Yes ❑ No Condition. <br />J;;es side se�ver have al least 1% sloee from fhe buitdinc lo se�ver mainl [� Yes ❑ No D/esaibe <br />"�, e ail �uildir,, sev;er d�ain connec6o�s to the side se�ver been idenh(ied and !ocateA? [�'Yes ❑ No <br />;,'ave all prcperty storm drainaye connectiuns to the side sewer been iden(ined aitl located? [��es ❑ �o <br />.;as pronerty been ev�luafea for drainaae defciencies v;�fh findinys communicafed ;o property� o�vner? � Yes ❑ No <br />Installation Details: <br />::hai ;yp° and brand ef E3WD :vas installed a( this s�te (Clean Check B4�N, Grinder pump, etc.) �'�i3.4� ��1rc: k <br />:;nera ars (he devir,e instalied (general descnpLon, aftach mapj'% �C'.�: ��•� _ _�' e� � '}-1�� <br />_ �%�Cl�Zt� -- <br />lVas Ihera an� oiher sewer or stonn drGinagr. H�ork completed in cenjunction wiih ihe �14�D r:crk"% Is sc olease descnbe: _� <br />Installation Checklist: <br />��.��� all dosvnspouts and sito drainage disconnecled from upslream o( the QWD"? �s [� No Commenls <br />Dces �3VdD pesihonmg meels minimum slepe reyuiremcrt of > i%? !�es ❑ No Commeris: <br />i;,�n BWD Le pulled oul ter inspeclion and m2intenance after loosening ihumb screw� [�+�Yes ❑ No <br />I: 5';'��D !ocked into Ihe proper position and �humb screw tightenedl Vy es ❑ No <br />C r�le the BWU cover iuiga�ti'ea�wer�and�sc�a e a� ); traffic load, /6earing cover (drive surface)1 access hatch (buildino) <br />':i'as property o:;ner sho�vn tf e �oca on of th� installed BN�D? � es <br />L�Y ❑ No Commenls: <br />P�nceitv Owner s Signafure: ! � � Date: �/L��LS <br />�nsialler's �ignature: ���,,� � � _ �/—_ <br />� - ' u^�� Date +�/�� �r 5 <br />��^Vi51Uf1: ,� � // <br />� �Uionday, Septem eb r 15, 7.014 <br />