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BACKWATER PREVENT�ON DEVICE FINAL <br />�. INSTALLATION CHECKLIST <br />Te%m�✓Y10/�a� 3G0-?{l/-g75� <br />Installation Company Name and Contact Info:lti�Z Caw{YticF�rS��-G �a� ua � yzs"g�E -7 3a5 <br />tl-4 fkru l�'S �l ti <br />Date Backvaater Prevention d�vice (B�UD) v�ras installed:__ Dale this form wzs completed: I�- 6-i5 <br />Installation Property Ovaner Name and Contact Inio: �?�'+acvn q Z( a(o �/2 5- 97/ ��O71 <br />Prooert/ Address: �G23 ��: �l:-�.�l�� /a✓L�i Ei/PI-P�, W�9 ryB�� <br />Pre•Installation Inspection Checklist: <br />All dems must 6e checked 'Yes' in order lor a BWD to be considered Ior installation <br />is there a basement or level oi the house thal is at or near assumeJ sewer m�in elevation? � Yes ❑ No <br />Are lhere 5xiures ia the house located beloe� lhe upstream seu•er manhole rim elevafion7 �j Yes ❑ No <br />Is the side sewer currently UNPROTECTED from se�ver backups (does noi have a BWD instal!ed)? � Yes [ �b <br />Site Inspection Checkiist: <br />Alf items must be checked 'Yes' before inspectron is considered complete <br />1rJas side searer TV inspecled (rom building to sewer main7 [� Yes ❑ No Condilion: � <br />Does side sewer have at least 1°h slope from the building fo sewer main? �C] Yes ❑ No Descrihe: �_ <br />Have ali building sev�er drain connections to the side sev�er been identified and lo�ated7 (3� Yes ❑ No <br />Have all property storm drainage connections lo th2 side sewer been identified and located? [�,Yes ❑ No <br />% <br />Has properly been evaluated for drainage deficiencies wilh findings r,ommunicatetl lo property owner? [� Yes ❑ No <br />Installation Details: <br />N�hat type and brand o( BWD w�s installed at ihis site Clean Check� N�V, Grinder pump, etc.): C I Ck� C.�t��lr y� <br />Where �aas the device installed (aeneral description, attach map)? �R� 2�._ _T_/f ��'«��� �__ 1� ��'r� ��a��rA, <br />�'ne. ?•3� �� SP�.��' Mnr1,7 ��cP• —T <br />Was there any other sewer or storm drainage �:+ork completed in conjunclion with tne BWD e��ork? is so please describe: _ <br />�7 croTf�i��Pc! �f S�J�� _�'^-f—L�uS P��1�LE�rP4) c�n�— ) iJ��S ��� `��-�"'�J(z r�acr�b�� �hl.�. <br />�--- <br />Instailation Checklist: Q�,,,� �1�,,,,,fp�.�� <br />Are all do�vnspouls antl site drainage disconnected from upslream of ihe Bl4�D? � Yes ❑ No CommeNs �; Y�.� �.�,/ ?� <br />re_�,:..t��. <br />Uoes BWD positioning rneets minimum slope requirement of >1°a? j�f Yes ❑ No Comments: ____ <br />Can BWD be pulled out for inspection and maintenance aPer loosening thumb screw7 O7j Yes ❑ No <br />Is BWD locked into the proper posilion and thumb screw tightened? [� Yes ❑ No <br />Cirde the BVVD cove . lrigation cover (landscape area� traffc load bearing cover (drive suriace) I access hatch (building) <br />Was property owner shown the location of ihe installed BWD? (�j Yes ❑ No Comments: <br />Pwperty O�t�ner's Signature��C/'�� /� Date: N�6 '/ S <br />Installer's Signature: �-Q �i'C�C Date: !I - l-is <br />Revisian: 7 1 Friclay, September 12, 2014 <br />