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BACKWATER PREVENTION DEVICE FINAL <br /> I�ISTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: u��en �[�wvpr�c< 2n(0 4vin - t>S29 <br /> Uate Backwater Prevc ' �n device(BWD)was installed: /Z^ /(o-i9� Date this form was compleled: rL-l7 - �S- <br /> Installation Pmperty Ov,ner Name and Contac�Info: nnarz= Pn-r l��pS�.-� <br /> Properly Address: ��AZ �.eck.�� l �✓� q�s �r,�-rr i,.,,�,_ i,92o I _ <br /> Pre•Installation Inspection Checklist: <br /> ,411 itei�s must be checked `Yes'in order�or a BWD lo be considered(or installation <br /> Is the.-e a basement or le��el of lhe house that is at or near assumed sewer main elevation?["f Yes ❑No <br /> Are �he�e fixtures in the house located below ihe upsirzarn sewer manhole rim elevation?QYes ❑ No <br /> Is the side se+n�er currently UNPROTECTED trom sewer backups(does not have a BVdD installed)?�es ❑ No <br /> Sitc Inspection Checklist: <br /> All items must be checked 'Yes'beforv inspection is consider�d complete <br /> t <br /> 4Jas side sewer TV inspected trom buiiding lo sevrer main? �'Yes ❑ No Condition:_� oc D C�n �i P� i <br /> Does side sev�er have at least 1%sl�pe from the building to setiver main? [r]'Yes ❑ No Describe: <br /> , <br /> Have ail building sewer drain connections to the side se�ver been iden;iGed and located? 0"Yes ❑No � <br /> Have all property storm drainage conneclio�s to the side sewer been identified and located? ;3 Yes ❑ No i <br /> Has property been evalualed for drainage deficiencies with findings communicated to property ovmef? �]Yes ❑No � <br /> Installation Details: <br /> N'hat type and brand of BWD was installed at this siie(Clean Check BNN, Grinder pump,�Ic.): �'�'-''�-' G��'� j <br /> N'here�vas the device installed 1 eneral descri lion, attac ma � L��F� S�o � � <br /> 9 P P). c, nF C;ac� Wna2 � <br /> lr�c�S7 C�o o�-= l-1vr+�v I <br /> Was there any olher sew,er or storm drainage work completed in conjunction vith lhe BWD work? Is so please describe:_ <br /> Installation Checklist: <br /> Are all do�+�nspouts and �ite drainage disconnecte�(rom upsiream oi fhe BWD7 Q Yes ❑No Comments: <br /> Does 6lND posiGoning ineets mir!mum slope requiremenl of>1%? �Yes ❑No Camments: <br /> Can B1��D be pulled out(or inspe�tion and maintenance after loosening Utumb screw? �'es ❑ No <br /> Is B6ND locked into the pro er o ition and lhumb screw lightened? [i]'Yes ❑No • <br /> Circle the BWD cov r: irrigalion�er�(andsca�e area)I traific load bearing cover(drive sudace)1 a�cess halch(building) <br /> Was property o�mer shown the location oi ihe installed BWD7 �es ❑No Comments: <br /> Property Owner's Signature: M�R 1 ��w4, �U d�f9-�- Dale: �� �I�'� I� <br /> Insteller's Signature:�r '' �- -- - Date:%z—�� — �g <br /> � <br /> Revision:2 1 Tuesday,Septembcr 16, 2014 <br />