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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Ins1��Ilation Company Name and Contea lnfo: J97`� �r+�tbi��c+ �� ��?r���"0/Z 3 _ _ <br /> Date Badcwaler Preventlon device(BYVD)wes installed: �/—/5 —2 U Date this form was campleted: U�o'�S^ <br /> Inshaliation Property OwnerName and Contad Into: 1 �+'"� W�`;� ��� ��' �� � <br /> ProperlyrAddress: Z�IIP lZ�t�-✓ �{�-�� <br /> Pre-Instellatlon Inspecdon ChecMist <br /> All i(ems must 6e d�edced'Yes'in order fora BWD ro be considered forinstellation ,,-,,,� <br /> Is there a basement ar le�el of the house fhat is at a near assumed sewer main elevvaati�on?1�res �No <br /> Are fhe�e PoAures in the house IocaUed Delow Ihe upsheem sewer mmihole rim elevatlon7[I]-Y�s, []No <br /> Is the side sewer currently UNPROTECTED fiom sewer backups(does not have s BWD Instelled)?[1]af�s ❑No <br /> Site Inspectlon Checklist <br /> All i6ems must be ahedced'Yes'before Inspedion is considered complete _ <br /> Was side sewer N inspeGed irom building to sewer main? ��� �ditlon: �n�-o�'��s'�"t" <br /> Does side sewer have at least 1°,6 slope finm the building to sewer main? �.Yes ❑No �esc�ibe;— <br /> Have ali building sev+er d�ain connections to tlie si ie sewer been iden6fled and located? (j7,Yes ❑No <br /> Have all property stortn d�ainage connections to the side sewer been identified and located? [�Ne� �No <br /> Hes properly 6een evaluated tor dninege defiaendes wilh findings communicaled to propeily owneY? [I,�1'� ❑No <br /> Installa6on Details: <br /> What type end 6rand of BWD was installed at this s'Ae(Ciean Chedc BV�V, Grinder pump,etc.): n—�-5'�'-��;--1-� <br /> Where was ihe device inslalled(general desaiption,attach map)7 �-�-�^'��'*'�� <br /> -��`� °'.dt � <br /> Was there any other sewer or stortn drelnage work compteted in conjunction with the BWD woil�t Is so please desvibe:_ <br /> N�^e- � - <br /> Installa8on cnecklfet: <br /> Are afl dovmspouts and site d�ainage disconnected from ups6eam of Ne 8WD? (�s ❑N� Comments: <br /> poes BWD p�s�ioning meeb minimum slope requf�ement of>t°67 � ❑No Comments: <br /> Can BWD be pulled out for inspection and maintenanoe after toosening Numb saex? [�}'f�S ❑No <br /> Is BWD lodced into fhe proper positlan an u �xew tightened? � ❑No <br /> Circle the BWD cover.irtigafion co r(landscape a�ea trafl'ic load bearing cover(drive surfaoe)/acoese hetch(building) <br /> Was property owner shown the location of the insialled BWD? ��� Cumments: <br /> Properry Ovmer's Signature:E� �ate: N—Z�'� 1 <br /> Installers Signature: <br /> oate: �1��—�� <br /> Revision:2 1 Friday,September 12,2014 <br /> I <br />