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' BA�;KWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLi�T <br /> Insiallation Coropany Name anc Contact Info: �.,-�r�`1 �� �Li�� t�L��,v„5 in!(, I n�( <br /> Dale Backvaa;er Prevention device (BN'D) was installed:�5��7o�zvt� Dat ihis form tivas completed� � Zr ?l:{5' <br /> installalion Property O�:�ner Name and Contacl Info: .�������� ��e�,Qqy� <br /> Preperty Address�_1�,;Z ���`���e ���j���L����•l <br /> Pre•Installation Inspection Checklist: <br /> liil;tems must be checked 'Yes'in order ior a BWD to be considered for mstaUaUon <br /> �s Ihere a basemr.ni or level oi lhe hou�e fhat is at or near assumed sewer main elevation7 ,Yes ❑ No <br /> Are ihere fixtures in the heuse lor.ated helew Ihe ups(ream sewer manhole rim eleva(ion? �Yes ❑ No � <br /> Is ihe side sewer currenfly UNFRUTEC i�D `�em se���er backuos (tloes no, nave a BU�U installed}? es ❑ No <br /> , Site Inspection Checklist: <br /> Afl items must he r.hecked 'Yes'b��are insnec6on is consiaere�d c olete <br /> l^,�as side se��ver TV inspected irom building to sewer main? I✓ y�s ❑ No Conditicn: <br /> Does sidE sewer have at least 1'io slope (rom the buildin to sewer main? � <br /> 9 Q Yes ❑ No t]escribe: <br /> Have all huifling sewer drain connections to the side se�ver 6eQn identified and located? []Yes ❑ No <br /> Have all properiy slorm drainage connections to±he side sewer heen identified and located? �vyYes ❑ No <br /> Has property heen�valualed for drainaae deficiencies�vilh findings communicated lo proper:y owner� �]'Yes �] No <br /> Installation Details: <br /> b'a'hal lype and hrand of�WD v,as inslalled at this site(Clean Che�k 81hN, Gnnder pump, etc.) S){�c����I„��� <br /> �Ahiere was Ihe device mstalled(general descriplinn, attach map)� �o,�-� s'�,�,� �•eu - .c 6 auf <br /> � ' ���' d•G _�-�' <br /> u., i� <br /> lVas Ihere any other se�ver or storm drainaye work comoleted in conjunction �vifh the 4WQ �vn;k? Is so please describe: (v�� <br /> Installation Checklist: <br /> P,re ali doe+nspuuts and sde drainaye disconnected from upslream o1 the BWD? Yes ❑ No Commenis <br /> Does BI�VD posi�ioning meels rtiinimum sloNe reyuirement of >1%? [�] Ycs ❑ No L'omments: <br /> Can RWD be putled oul for inspection and maintenance after Inosening fhu h screw? [�Yes ❑ No <br /> Is 13WD locked inlo Ihe prooer pesition and lhumh screw tighlened� Yes ❑No <br /> Cirdia lI1P. BWD CUVP.0 IM ��w� (lanc�s apa rea)/iraffc load hearing cover(drive surface)!access hatch (buitdiny) <br /> �1�as property uumer shown Ihe location of ihr, installed ON/D? ��s ❑ No Commenis' <br /> Prope�(y Owner's Signelure:' y/ /J �J <br /> F������1� _ Dafe: ,S— ' Z�_ <br /> insialler'sSignalure: '��(��.���,y��,� _ _ Dale: S Z� Zo� <br /> Rcvision: 2 � ✓ � <br /> t ��londay, Seotemher 15 )nt.� <br />