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� � BACKWATER PREVENTION DEVICE FINNL <br /> I <br /> ,• INSTALLATION CHECKLIST <br /> ! <br /> Installation Company Mame and Contact In(o: C����1 �('S�LL�S! 1""�-v�'t�1�5 IA�(-�Tj n; ( , <br /> Date Back�valer Prevenlion device (BVJD)was installed: � �5 i 5I Date ihis torm was compieted� � �/ f �5 <br /> Installation Properiy Owner Name and Contact Info: �o�� �a�lker-- 4t5- 30�-�. - i 3`11 <br /> —___�_ <br /> PropertyAddress '2ltq �,;kQ��(�,�,�._ �u� �� ,{�,�..�� �j4 9FZc�1 <br /> Pre-Instaliation Inspection Checklist: � <br /> FlII i!ems must be checked 'Yes'in order�or a BWD to be considered lor�rnstallation <br /> Is �here a basement or level of the house that is at or near assumed sewzr main clevation? [�es ❑ 1Jo <br /> !ve there fxtures in the house located below the upstream se���er manhole rim elevation?(�Yes ❑ N <br /> is the side sewer r,urrently UNPROTECTED trom sewer hackups (does not have a 4VVD insla!led)? ✓ Yes ❑ No <br /> Site Inspeclion Checklist: <br /> i <br /> ,�II items must be�;hecked 'Yes'be(ore inspection is considered comp'ete <br /> YJas side sewer TJ inspected irom building lo sewer main? v�Yes �No Condition: <br /> Does side se�:�er t�ave ai least 1%slope from the building to sewer main7 �Yes ❑ No �escri6e <br /> Have all building se�,ver tlrain connec��ons to ihe side se�ver been identified and located? [�Yes No <br /> Have all property:;torm drainage conneclions to the side sewer been ide�lified and located9 Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings com�unicated to property o�mer? [�Yes ❑ No <br /> Installation Details: ; <br /> l'lhat type and 6rand of DWD�vas installed at lhis site(Clean Check BUVY,Grinder pump,elc.}: �(ra.�C�„«k <br /> �'/here was the device instal le�d (general description, attach map)? ��:�arrT� �npar -H,e- �s I ewd,..� <br /> �i,�_-� dec�' ) <br /> � <br /> 4Vas Ihere any other sewer nr storm drainage�vork compleled in conjunction wilh ihe BWD�vork? Is so pl^:is��descrihf� IJ o <br /> i — <br /> -- — � <br /> Installation Checklist: <br /> !ue all downspout� and site drainage disconnected trom upsUeam of lhe�WU? es ❑ �o C;rrunenis _ ___ _ <br /> Dnes BWD posilioning meets minimum slape requirement o(>1%? [.] Yes ❑ No Comments <br /> Can 8WD be pulled out for inspection and maintenance after iooseniny th�umb screw? [..f-Yes ❑No <br /> is BWD locked into the proper position and thumb screw tighlened? B�s ❑No <br /> I <br /> ;,irde ilie E3lND wver. irrigation cover(lantlscape area)l lratfic load bearing cover(drive suriace)/ar,cess natch(building) <br /> t'�ias property owner sho�;fi lhe Iocalion of the instalied BWD? [�.�(� � No Comments: <br /> / <br /> Prrpe�ly0wner's�ignature:_ _�� �.. ' ,Dale:�- �l�/� 0/1 � <br /> Installer's Signalure�: _ �- .5,� � � <br /> Dafe: �/ 1 � S <br /> Itev�sion: 2 l I Monday, Septembe� 15, 2014 <br /> { <br />