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� BACKWATER PREVENTION DEVICE FINAL <br /> r INSTALLATION CHECKLIST <br /> Inslallafion Company N2me and Conlacl In(o: I� ��r�'1 r�� rl�.` �C. �rt�; �(�• L , <br /> Date Back�vater Prevenbon device(BWD)was installed: a I�I y Dale this form was completed A 2yi I 5 <br /> 9nstala�ion-Propedy`_0"v;nerNarrL��d-Contacllnfo:�'n� �iha� �n Sy��e�ter <br /> ?�,ry�>a��e55_ Ilo1 gu� Rve_ �eve�-WA- �zo � — <br /> Pre•Instailalion Inspeclion Checklist: <br /> All i;enis must Ce checked 'Yes'in order�or a BWD to be consioered lor inslallation <br /> Is(here a basement er level oi the house ihat is at or n�ar assumed sewer main elevatien? �es ❑ iJo <br /> A�e Ihere fxtures in the house lor.a(ed below lhe uosiream se:ver manhole rim elevation? [�fes ❑ �o <br /> is ihe side se�:�er currendy UNPROTECTED from sew�r b=c%ups (dces not have a L�WD instrlled)? [�es [� �'� <br /> Site Inspection Checklisk <br /> AG i!ems must be ci•,ecked'Yes'6efore mspertion is r.onsidered cnr,plete <br /> ,r�'as side sawer TL'inspected from building lo sewer main? [}'4es ❑No Condition: <br /> Onrs side see:er iave a;least 1",o slcpe Irom the building to sev�er main7 (-�es ❑Nn Describe <br /> Have ali build�n�sev,r.r dram connec�ians to Ihe side se�aar hee�idr.nGLed and loca�ed? [�es ❑ No <br /> f lave�il prooerty slorm drainage canneclions to lhe side se�ver boen idr.ntified and lor,ated? [j yes ❑ No � <br /> Ha�; propeny I?een evaWated Icr drainage defciencies with lindings communir.�ted to preperty o�vner? [�}'�es (] IJn � <br /> Installation Details: I <br /> �V1iat ty�pe and�rand of BWD was installed al this sife(Clean Check 6W1,', Grinder pump,etc.): C�ean Ch uk <br /> 1^Iheie ti•�as Ihe devir.e ir.stalled (general description, nlUch ntap�? _ �1� q�� <br /> ----- �-�--�—�'`—`�"�- I <br /> 1Vas ihr.re any olher sev✓er or storm draina,ye�^.�ork coinpleled in conjuncfion wi(h Ihe t3WD e�nrk? Is so please describe <br /> —��- -- ------ -— <br /> Inslallaliun Checnlist• -' <br /> Are �II dovmspouls ;�nd sile drainage d�,connecled from ups(ream of Ihe BWD7 [�es [] No :Commenis: <br /> Cur:s [lWU positianlny meeis mininium slnpe requiremenl 0l>1'%? �v��s ❑No Commenis! <br /> C.in BWU Le pulled oul for inspectian anA maintenanr.r,after lonseniny ihumb s:re�v? [�Yes ❑ No <br /> L;(3��Vf)ler.ketl inlo ihe proper position and thumb scrow lighlened? �Yes ❑ No <br /> Cirr.lr. Ihe �4VD cuver �ntq, on cover andsca e are• Ira(fic load t�aring covet (drive�urface)I access halch Ibuilding) <br /> � <br /> ✓ <br /> bV�s properiy owncr shuwn Ihf:lo� ' f ihe inst Iled BV�/D? ;��5 (] No Cammen�s: <br /> ; Proper}y�0��;ner's'Signal�arer4�Ilti1�' � -�_" -- ( <br /> ` ------ �te-_ ' � 2a I y __ I <br /> Inslailler's Signature..���� <br /> -- __ Date:_�� 15 � <br /> iicv�sion: 2 1 � <br /> Munday,�eptember 15, ZOtq <br />