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i <br /> BACKWATER PREVENTION DEVICE FINAL ; <br /> INSTALLATION CHECKLIST f <br /> i <br /> ; <br /> � <br /> Inslallation Company Name and Contacl Inio: �r'o/% ��li/'�I3 rn �/ j <br /> Date Backv��ater Prevention device(BWD)was installed: � /' Date this form was completed: j <br /> i <br /> InstallaGon Propedy OwnerName and Contacl In(o:��Z ti+���;� � <br /> i <br /> Properfy Address: /2 7!o jZucl�rr ��� <br /> i <br /> Pre-Instaliation Inspection Checklisl: � <br /> Af!items must 6e checked'Yes'in o�der(or a 8V✓D to be consrdered for installetion i <br /> Is there a basement or level oF ihe house that is at or near assumed sewer main elevation?(�Yes ❑No � <br /> Are there fixtures in the house located b21o�v the upstream sewer manhole rim elevation?�i Yes ❑No � <br /> Is the side se�•�er currently UNFROTECTED from sewer backups(does not have a BWD installed)�Yes ❑No � <br /> Site Inspectlon Checklist: ; <br /> All items must be checked'Yes'be(ore inspection rs considered complete <br /> Was side sewer N inspected from building to sewer main? �]Yes ❑No Condition: ; <br /> i <br /> Does side sev;er have at least 1°/o siope from the building to sewer m2in? .�]Yes ❑ No Describe: ; <br /> Have ali building se�ver drain connections lo ihe side se��ier 6een idenlified and localed7 �Yes ❑No ' <br /> Have all property storm dralnage connections lo the side sewer been identified and looated7 p Yes ❑No <br /> Has property heen evaluated(or drainage deficiencies with findings communicated to property otvner?�Yes ❑ No ? <br /> ' <br /> Installation Details: ; <br /> Whal type and brand of BN.�D was inslalled at this site( an.,heck B ' rinder pump,etc.k j <br /> VJhere was the device installed(general description,attzch map)? _;;tiS r a�� -�„�i P��: L✓�,ik wr�y � <br /> � <br /> in �� �//ry � <br /> N�as there any other sewer or storm drainage work completE:in wnjuncfian wilh ihe BWD erork? Is so please describe:, ; <br /> ti.d � <br /> i <br /> installation Checklist: ; <br /> Are all dow�nspouts ar�d site drainage disconnected(rom upstream of the BWD7�Yes ❑No Comments: � <br /> Does BWD positioning meels minimum slope requiromentof>t%7 �Yi�s ❑No Comments: j <br /> Can BWD be pulled out for inspection and maintenance after loosening'trhumb screw7 /�'es ❑No � <br /> Is BVJD locked into the proper posilion and tliumb screw Ughtenedl ,FJ Yss ❑No � <br /> C�xle the BWD cover.irrigation cover(landscape area raf3icioa` earin�� rive su ace) a cess hatch(building) ; <br /> Was propedy ovdner sho�m the local', n lhe inslalle 't� ��D�No Comments: ; <br /> c /, �, � ,- _ I <br /> Property Owners Signature: / '''— � / �lDate:_.1��� �-� � <br /> --`�--� � <br /> Installers Signatu . Date: �///3%i.r'� : <br /> _ ; <br /> Revisfon:2 1 Friday,September 12,2014 � <br />