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� <br /> I <br /> B/aCKWATER PREVENTIOiV DEVICE FlfVAL '+, <br /> � <br /> d iNSTALLATIOfV CFIECKLIST ; <br /> � <br /> r�neri c�zn x{� � c � ���� sc'-�L�r', L LG ' <br /> Installation Compzny ��ame and Contact Info:,���C.0 Q;�r�/4a�; -C�S�/���=i i�rlt �:K�,)'��i0 a?CJ��";2 � <br /> Date Back�vater Preeention de��ice(BWD)was installed:,����_Date this form was compieted� 41�/,es_ � <br /> Inslallation Property Owner Name and Contact Info: � <br /> Prope�iyAddress:�,Q� �jllG Pi" �1Q�, Ft)�'/f� q�'•�� <br /> Pre•Installation Inspection Checklist: i <br /> All ifems must be checked'Yes'rn order for a BWD to be considered tor installation � <br /> Is there a basement or level oi the house that is at or near assumed sewer main elev2tion?(�Yes ❑No � <br /> I <br /> Are there fixtures in the house located below the upstream se�ver manhole rim elevation? �Yes ❑ No <br /> i <br /> Is the side sewer currently UN�ROTECTED from seti�er backups(does not have a B�4�D installed)?�'Yes ❑ No , <br /> Site Inspection Checklist: � <br /> i <br /> All items must ba checked'Yes'before inspection is considered complete � <br /> INas side sevrer TV inspected�rom builtling to se�ver main? L�Yes ❑No Condition: ��aQ c� <br /> Does side sewer have at least 1%slope from the building to se�ver main? �1'es ❑No Describe: � <br /> i <br /> Hz�re all building see�er drain cornections to Ihe side sewer been itlenlified and located? [�'es ❑ No � <br /> ( � <br /> Have all property storm drainage conneclions to the side sewer been idenlifled and located? [�-Yes ❑ No ' <br /> i <br /> Has property been evaluated for drainage deficiencies with findings communicated lo property owner? [�'Yes ❑ No <br /> , <br /> installation Details: [ � <br /> What type and brand of BWD svas installed at Ihis site(Clean Check BWV, Grinder pump,etc.):�C�Y� i <br /> ' �CT["�tO�I �-G.�U,Cti(;�' I <br /> N�here tvas the device installed(general descnption,atlaoh map)? S(°C (�a <br /> Was there any other sevrer or storm drainage work comoleted in conjunc(ion wilh the 8WD work?Is so please describe:_ <br /> ��C�}��P — <br /> ; <br /> Installation Checklist: <br /> Are all downspoufs and site drainage disconnected irom upslream o�the BVJD? �Yes ❑ No Commenfs: ; <br /> Does BWD positioning meets minimum slope requirement of>1%? �Yes ❑No Comments: � <br /> Can BWD be pulletl out for inspeclion and maintenance after loosening thumb screv+7 �Yes ❑ No i <br /> Is BWD locked into the proper position and thumb screv:tighlened? �Yes ❑ No ! <br /> Circle Ihe BWD co r. irngaGon cove ndscape area)1 traffc loatl bearing cover(drive surface)I access hatch(builtling) � <br /> l4�as property owner sho�.vn Ihe �ocation 0f ihe installed BWD? �'1'es ❑ No Comments: <br /> ^ � , <br /> v\. Le ' �� I <br /> Property Owner's 5ianature: Date: <br /> i <br /> Installe�s Signature: Date: U� ZD —20/j I <br /> I <br /> Revision: 2 1 Friday,September 12, 2014 ! <br /> i <br />