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i <br /> i <br /> BACKWATER PREVEN�ION DEVICE FINAL � <br /> Q, INSTALLATI�fV CHECF(LIST i <br /> ! <br /> �r►can �,x;/� � � � ��d� : e-���, L LG ; <br /> Installalion Company Name antl Contact In(o:S�CC j��� (' J�)-�44-�l�i 5����i��.�`�`��)O a?/7�� I <br /> Dale 8ackw2ter Prevention device(BWD)was installed: 4 I7 )�Date this form was completed: � <br /> ( 387- i <br /> Installation Property O�vner Nama and Contact Info"�yY�.c� I S E� Yl C Q � �Yl. . � �G, � <br /> Property Address:���1�,�LP�'��(�l't..1 � ��/l-� q �a o� i <br /> i <br /> Pre•Installation Inspeclion Checklist: � <br /> All ifems must be checked'Yes'in order for a BWD fo be considered for installafion 1 <br /> � Is there a basement or levei o(lhe fiouse that is at or near assumed sewer main efevation?[�Yes ❑ No � <br /> Are Ihere fixWres in the house located below lhe upstream seerer manhole rim eleealion?[�Yes ❑ No � <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [�Yes ❑No � <br /> Site Inspection Checklist: + <br /> All items must be checked 'Ves'before inspecfion is considered complete : <br /> Was side sewer TV inspected from building•to se�ver main? �Yes ❑ No CondiGon:��� � <br /> Goes side sevrer have at least 1%slope from the building to sewer main? �Yes ❑ No Describe:_ � <br /> Have all building sewer drain connections to the side sewer bean idenlified and localed? �'�Yes ❑No � <br /> Have all properly storm drainage connections lo the side sewer beon identE(,ed and located? [�'es ❑ No i <br /> Has properly been evalua�ed for drainage deticiencies wAh findings communicafed to property otvner? �Yes ❑ No , <br /> ; <br /> Installation Details: � <br /> VJhat lype and 6rand of BWD tivas installed at ihis sile(Clean Check BWV, Grinder pump,etc.):�E��� ! <br /> 14�here was Uie device insfalled(general description,allach map)? ���__ ('i �G�'.,_U��___���7Lf,:1� j <br /> I <br /> Was there any other sewer or storm drainage work comple�ed in conjunetion with the BWD work7 Is so please describe:� ^ <br /> — - 1� � i <br /> Installation Checklist: ( <br /> Ara all downspouls and site drainage disconnected from upslream of the BWD? [�Yes ❑No Comments: � <br /> Does BWD positioning meets minimwn slope requirement of>1%7 �Yes ❑ h'o Commenis� <br /> Can BWD he pulied out(or inspection and maintenance after ioosening ihumb screw? [��Yes ❑ No ; <br /> Is BWD locked inlo the proper-posifiunalnd ihumb scre�v lighter�ed? �'Yes ❑ No i <br /> Circle ihe BWD co r. irrigation cover fidscape area)!traffic load bearing cover(drive sudace)1 access halch(bulltling) f <br /> � --- ! <br /> Ut�as property owner shown the ocation o(the installed BWD? [�Yes ❑ No Comments: <br /> / ( <br /> ���// ��' { <br /> Property Owner's SignaWre: 7 Date: , <br /> � <br /> Installer'sSignatur ^ Date: y` � — L� i <br /> � <br /> i <br /> Revision:2 1 Friday,September 1J,2D14 � <br /> � <br /> i <br />