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. i <br /> r <br /> BACKWATER PREVENTION DEVICE FINAL <br /> � rr iNSTALLATION CHECKLIST <br /> Inslalla!ion Compan,Name and Conlar.l Info:�C=J____ -l7� � 7��f " ! r � � <br /> Date Back�vater Preventinn d�vice jBWD) was inslalled:_�'��'� 3 D��f�a Ih�s I�mn ;oas complcled G —/ S" �S! <br /> Inst;llation Property Owner Name and Confar.( Infa �-.J�rF C/��LO �O '775 "7 S�• .5�/� � <br /> PrGperyAddress: �yE�__�J�K� � <br /> Pre-Installation Inspection Checklist: <br /> A!1 items must be crecked 'Yes'in order for a BI��D to�e considered(nr ii�sfallat,��� <br /> Is ihere a basement or leve�or Ihe house that is at or near assumed se�ver mam e�eva6on� L?�'es �]Ido <br /> Are there fixtures in the house located belor�ihe upsL•eam sev;er manhole rim elevafion��'Yes ❑ No <br /> Is Ihe s�de seerer curren(ly U��PROTECTED from se�ser backups (does nof haee a. f?l�!�D uista!le�j� �_=✓, 1'es I.�Ab <br /> Site inspection Checklist: <br /> All items must 6e checked'Yes'be(cre inspecfion is considered con�plele <br /> Was sid� sewer N inspected (rom bu�ld�ng lo sewer main? �es ❑No Cond�!�cn <br /> Does side se�n�er have at leasl 1% slope(rom the 6uilding to sewer main? [3'Yes ❑No Descnbe _ __ _ <br /> Have all builtling ser:er drain conneclions to Ine side se�:�er been idenGfied and Incaled'� ��"1'es [� Nu <br /> Nave all property storm dramage conneclions Io lhe side sewer hecn idenlified and localed� ��Yes ❑No <br /> Has property been evalualed for drainage deficiencies r�ith 4ndings communicaled In property owner� (,�"S'es (� tJo <br /> Instailation Details: <br /> 414�af type and brand of 9Ut�D was inslalled af ihis sile(Clean Check B�VV, Giinder pwnp, clr.):G�Gi1+�( C��G�L <br /> 1't�here�vas lhe device installed(general descriplion,�Ifach map)� tj t4-GIL ��L�c� >� ��Z�`F�� <br /> tR'as Ihere any other se:ver or storm drainage work r.omplefed in conjunction�aith Ihe RWD�ti�ork?Is so please descrihe <br /> —— —_�t) _ — <br /> Installation ChecklisL <br /> Are all dow�nspouls and site drainage disconnected(rom upslream of Ihe UWD'� r�Yes (]No Commenis <br /> Does E3WD posilioning mects minimum slopc requiremr.nf of>1"/0? �y"Ycs ❑ No Cominenls __ _ __ <br /> Can�UUD he pulled out tor inspeclion and mainlenanr.e after looseninq �humh sr.rr.iv? (,'rYes �_ �No <br /> Is B4V�locked in(o the pioper � �iun and tlwmb screw lightened� [�r,; ❑ No <br /> ) <br /> Circie lhe BtND covec ahon co .r-(�ndscape area)/iraftic load beanny cover (drive sw facr_}!,ir,cess haich(building) <br /> L�Va>property orvner si , n ihe locatior.o!Ihe inslatletl D§i�D� �; [ ] No Comnicnl5 <br /> Properly Ocmer's Signalur _ Da(e: ___J / ( 7� <br /> �_ /— ,—L��------ <br /> Ins�all��r's Signalure �__ __�� ' `—�-- _ D,ile ' /3 "/5 <br /> -� -�'—� --- --- <br /> Rft�r�inn� ? 1, Ivinnd;iy, i���:l�.•�nhri ii, %fil4 <br />