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� <br />' ev <br />� �� <br />BACKWQ.TER �REVENTION DEVICE FINAL <br />iNSTAI_LA�IUN CHECKUST <br />� <br />; <br />r.�l::'� �:ion Crn�pa iy'Jame and Conlact Into: _.,_� �'�'1 ri'� t!.L } S �- V�1� i5 If�{.� ��; (. _ <br />Dafe 9ack:v�,�r Prevention device (BWD) e�as installed: 6l-'-� _ l� Cale this lorm t:�as completetl.��'�-15 ., <br />Installation Preperty O�;ner Na�ne and Contacl Info l..i i �� ihM L`uriJ •�-111� •?� k- 7�45_�__ <br />Froperty Address ._�i'_1 I 1�uertf�U.�2_ P�✓r_ E✓cL�E1—w��--- � 2r ---. <br />- �---- <br />Pre-Installation Inspection Checklist: <br />!+I! i!ems must 5e checked 'Yes' in order (cr a BWU to be considereo for instaAafion <br />i; �.n:;re a hasement or le��al of the house that is at or near assumed se���er main ele:at �n� ���}'�s _. f:o <br />'��c ;'•��re lixtu�es in tf�e house localed below the upstream sevrer manhole rim ele��aUon? I__�s '�j No <br />�� = s;de se�::ar c�.irrenUy UNPROTECTED Irom sewer backups (does nol have a B1'dC mst,3'��d;�� �[_�� Ne <br />Site Inspection Checklisk <br />�;il nems musf be checned 'Yes' before mspecfron is considered cornp�efe <br />'.'�' :; s�de sewer il+ inspected from builtling to se�ver mai�7 �s [�'I No Cord tion C�JG � _ <br />D- �s s�de se�ver have a; least 1;� slope irom the bulding to see�er main? �s ❑\o Describe. <br />i 1:::. :�il bwWiny sewer drain connections to th� side setiwr been identihed and localec? [t�f� ❑ No <br />i,�;-.� :,II u�operty slonn drainage connections to ihe side se�:er been �,deniife� and �ocated? �+'e`a ❑ No <br />tia�, ; io; erty beec evaluated for drainage deficienci�:s �;�(h 6ndings canmunicated fo property o�aner"7 �' �s '� �d�, <br />Inslallation Details: <br />':�!'i��at I�; ne :and brand of 6WD was installed at ihis s!�� (Gean C:�eck [31�VV, Grinder pump, e�c.)�. L��a., C�_c1� <br />,': r=rr e;as (i�e devir.e mslalled (general descnplion, atiar.h map)? VY�:� A�'TAC t\E� _ <br />,.:: � G��era ,�n� otLer ser,er or storm �itainage v�ork �:omoleted in cunjunction �a�ith the BV1'D �vork? is ,o nlease descn!,�� �,U <br />Installation Checklist: <br />;,r� ��ill du�•mspouts and slte drainuyc disconnected (�om upstream of Ihe dNJi)? ��es �] No Comments: <br />� ��c:; BWD posilianiny meets mi�imum slope reqwremenl of?1%�7 � , 'es ❑ No Contments�. _ . _,_ _ _ _ <br />����:n (3Wf) be pulled out (or inspection and mainlen,mce aller loosenmg Ihumb screw? [�es [ f No <br />!s Ll1'l) locked into Ihe proper positian and thwnb scre,; Iiuhlened'1 I�s ❑ No <br />C�ele ihe aN�D cover. irngation cover , andse p area � iraffic load bearing co���r (drive surtace; I a�cess halr.h (huiln'���;) <br />':' i, prooerty o�,�ner sho�ti�n fhe locaiion of the in�tsilled BVV�? �VJ res ❑ No Comntents: ___ ____ ___ __ <br />�`ape�ty �rmer's Signature�. <br />c-:t;�lb�r's Signature: <br />Rrvi��rn ' <br />— Date: —�l ��,5 - - ---- <br />Date: _�._L��� <br />I <br />A'��o�iday. 5�pt��mhrr LU, l01•1 <br />