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' BACKWATER PREVENTION DEVICE FINAL <br /> .� INSTAI_LA710N CHECKLIST <br /> � n <br /> Insfallation Company Name and Contact info:�_,,=���1 �/'��LL'S i'L�i,ti�fS IA�(���! � <br /> Date Backwater Prevention device (aWD)was inslalled:�3���/1�Daie this fonn was completed: �� Zy"� 5 <br /> •Installation Property.Owner Name and Contact Info� �-� D �� � �QSQ. _p���ly��,Z�� 5��4 <br /> Properly Address�_�.�_Q�_l� L�t l� e((� � L Il�•f'�e� r.v A g �Ol <br /> Pre-Installafion Inspection Checklist: <br /> All iferns musf be checked'Yes'in order(or a DIh�U lo be considered lor installation <br /> Is ihere a basement or level of ihe house that is at or near assumetl sewt�r main elevation?[�Yes ❑ No <br /> Are Ihere fixlures in Ihe house localed below the upstream sewer manhole rim elevation? �Yes ❑ No <br /> Is the side se�:�er currenlly UNPROTECT[D from sewer backups (does nol have a BWD insfalled)? [�r.s ❑ No <br /> Site inspection Checklisl: <br /> All iterns musl be checked 'Yes'be(ore inspr.ction is considered co ple(e <br /> Was side se�ver 1V inspec�ed from building lo setaer main? Yes ❑ No Condition: �� G� '- <br /> Does sid�sewer iave at leasl 1%slope from the building lo sewer main? �Yos ❑No D scribe: °'�) <br /> Have all buildmg sewer drain c�nnections to ihe side sev✓er been identified and localed? i Yes ❑ No <br /> Have all properiy slorm drainage conneclions to the side sewer been identifed and localed9 ��es ❑ N • <br /> Has property br.en evaluated tor drainage deliciencies wilh(indings communicated lo property owner'? (��es ❑ No <br /> Inslallation Details: <br /> Wha(lype and brand o(HWD�vas installed af this site (Clean Che;k 4lNV,Grinde, pump,e1c.)� GI e�.� �_h e�. -. Rr�✓ <br /> Where was Ihe device inslalled (general description, attach map)% ; �1� w .�-w�;d<�I.�o-F�ouS�__ <br /> i /� / <br /> c���D� . 5 �� '�'U V�C QT9D�l ____ <br /> Was Ihere any olher sr,v�er or slorm drainaye work completed in conjunclion�vith the 13Wp work9 Is so please desciibe: N.� <br /> Installation Checklist: <br /> �re �II doc+nspuuls and site drainagc disconnected from upsiream ot Ilie BVJD7 Yes � � No Commenis: <br /> Uacs DWD posiUoning mr.eis minimum slope requiremenl af�1%? ��Yes [] No Com ents: <br /> Can l3�ND he puped oul(or in:,pection and maintenanee after toosening Ih mb scre�v9 Yes �_� No <br /> I:;E3�ND locked inlo lhe proper pnsition and thumb screw tighlenedl ��es ❑ No <br /> Chcle the �1N�cover:irriry���({�u�apr.�i��f(a�e��cl6ear'ng r.over(drive sur(ace)f access hatr.h(buildiny) <br /> Udas properly ovmer shumm Ihe localion of the instailed f3WD7 [ c>s ❑No .Commenls: <br /> Propeity Owncr's Signaf�.�re: � �� �Q2� _� Dafe: �;� y- / �� <br /> Installer's 5ignafure:�/1�%�.P _i ���e. $/� �S <br /> � — ` 9� ------ <br /> Revaion: J 1 Mondiy,Septem6rr 1;, 2�74 <br />