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BACKWAT'ER PREVENTION DEVICE FINAL <br /> IRISTALLATION CHEGKLIST <br /> Insiallation Company Name and Conlact In(o: t'�o ��v.M (3,�.c, L� c_ �(Q-Q.Fi(P ,(�'j 29 <br /> Date Back,vater Prevention device(BWD)was instailed: (2—3 � -14 Dale this form was completed: �2 —3 t — �4 <br /> Instaliation Property O�vner Name and Contact Info:�'vL G!f w��y 4'LS= 2Sg - ¢0 2tc <br /> PrapertyAddress:�-�2�� Rvc�.r�E�l�n qvu CVc.J2�T`T 9820 � <br /> Pre-Installation Inspection Checklist: <br /> All items riust be checked'Yes'in orJer for a 3WD to be considered lor insfallation <br /> Is ttiere a 6asemenl or level of the house ihat is at or near assumed se�ver r�iain elevation?[�Yes ❑ No <br /> Arc there fxlures in the house loca',d belmv the upstream seH�er manhole rim elevalion?[�Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer hackups (does not have a BWD inst2'!ed)?kC]Yes ❑ No � <br /> Site Inspe�tion Checklist: <br /> All items must be checked'Yes'be�are inspeclion is considered complete <br /> Was side sewer TV inspected from huild;ng to sewer main? �'Yes ❑No Condition: D K CC L��_ <br /> , <br /> Does side sewer have at least 1%slope trom the building to sewer main? �C,Yes ❑ No Describe:_ <br /> Have all building sewer drain connections to the side sewer been identified and located? �Yes ❑ No <br /> Have all property stortn drainage connections to the side sewer been identified and located? �Yes ❑No <br /> Has property been evalualed for drainage defciencies wilh findings communic2ted to propedy ov+ner? �jYes ❑ No <br /> Installation Details: <br /> What type and brand of BWD v�as installed at this site(Cle eck BW1',Grinder pump,efc.): CL��r.i C,�c�� <br /> Where was the device installed (9eneral descripti attach map). <br /> Was there any other sewer or storm drainage work compleled in eonjunclion�ti�ilh the BIND work? Is so please desonbe:_ <br /> Installation Checklist: <br /> Are all downspouls and site drainage disconnected from upstream o(the BWD? f�Yes ❑No Comments: <br /> Does BWD posilioning meels minimum slope requirement of>t%? ,�Yes ❑ No Coinments: � <br /> Can BWD be pulled out for inspeclion and maintenance after loosening(humb scre�v? ,�'Yes ❑ No <br /> Is[3WD locked into lhe ro er ositio nd�lhu�nb screw tightened? (�Yes ❑No <br /> Circle the 81ND co er. irrigation co er anoscape area)f� nc load bearing wver(dnve surface)I access hatch(ouilding) <br /> Was property owner sho�ti�n the location of the inslalled BN�D^ ❑Yes ❑No Comments: <br /> Property Owner's Signature: ��_-� ---= - Dale:_ / 2 r 3 i - !c f <br /> Installers Signature: -.�—Ci/�L_ Date:_f 2 �- `3 � ^ �� <br /> Revision: 2 1 Tuesday,September 16, 1.01-0 <br />