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i <br /> fro�*: ;012012015 11 :34 �190 P.0021003 I <br /> 1 <br /> � <br /> BACKWATER PREVEN710N DEVICE FINAL � <br /> � I <br /> INSTALLATION CHECKLIST � <br /> InstaUabon Company Name and Con�c1 Info: `�1 W s '���" �/� N ' <br /> Date Backwele�Pre�en6on derica(BWD)xas in�faUed: I O 15 Dete ihis(orm xms canP(eU�d: � <br /> InsfaAatlon Prope�ty(hmer Name and CoNacllnfo: 1 LU l Cc�1,�1 C I-fttndu� 4�• 2�'i. G�2(.o Z I <br /> propeAy Address:_ Z�J�2 ��_�1�..L_y'��Z-Q� � <br /> � <br /> Pr�ln�lhtion Inspadlon Checl�llat � i <br /> AO rtrJns musf 6e d�ecked ryes'in oNer lor a(3WD to be caeddeied for insfaAetion • <br /> Is Cwro a basernont or Icvcl oi tho house that is et or mar essumed sewer main eievatfon7�Yes ❑No ' <br /> Are Nete fizhtres in Ihe house locahad beVow the upafnam sewcr ma�hde rim eleva6on9�Ycs ❑No � <br /> ts!he side sawer curtently UNPROTECTED Gom sevre-backups(does not have e E3WD irsta!'sd}?�Ycs ❑No <br /> Site Inepectlon Checldut: ' <br /> A!1 items mus!De d�ed'Yes'!�e(ae irrspection is considared complete � <br /> Waa side sewnr N inspecicd from building to sewer main? �Yus ❑Na CondiOon: <br /> poes side saurcr havc at teast 1°h sb,x trom ffie bulding m sawer main? �QYcs ❑No Drsaibe: <br /> Havc aV bwldir�sener drain wnnor�ions to the side xwer 6een tdcntified and localed? �Yee Mo � <br /> Hew a8 properly stortn drainuge connec5cxis to Me side sewer been identilied and locead9 Yas ❑No <br /> Has pmperty been evaluated for drainage deliciencies with fitrings communicated to propetiy owne(l '�Yes ❑No <br /> In�allatbn Detalis: \ ' <br /> What type aod Mand ot 8W�was instn!kd at this {Gean Chock UNN,CyfndIo'r�mp,elc.): j <br /> Where was the device insla(led(general dasuiptio ,a map -"� ���t`��« `t � rl C�1'� <br /> Was ifiere any o�her sewer or slorm draina�,w vYwk compleled in conjunction wth the BY�D workT Is so please dsscrfbe:u� <br /> Inetalktlon Cheekllsf: <br /> Are all downspouts aM site drainago disconnaled Irom upsfisam af the 6WD? �Yes ❑No CommenL� ; <br /> Does BWD positionmg meefs minunum sbpo raquirement af>1967 �1Yes ❑No Commonts: ; <br /> Cen BWD ba puYed oul for inspec6on and maintenance afEer looseninq Mumb saeufJ -�Yes ❑No <br /> � <br /> Is BWD bdcod into Ihe proper positio tighlened? Yes ❑No <br /> Cilde ihe BWD cover.iRigetion oo , pe area) traffic load 'ng cnwr(drive sunc�e)/nccess halch(building) ; <br /> Wes property ow�ner shown ihe Iocation at the in r BWD7 �'�v ❑No CommeMs' !_ i <br /> PropeAy Owners Signatwa:_ � _L-- �-/� Dab� �� � <br /> � <br /> I��Ilei s SlgnaWre:� .���: � -�f-I j <br /> Hevision:7 1 Friday,Scptember 72,7014 I <br /> I <br /> � <br />