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� <br />BACK�VATGR PREVENTION DEVICE FINAL <br />INSTALLATION C! :�";:LIST <br />Installalinn Company N�me and Contact Info: _��H�Ivxa <br />Date Back+vatc; Prevention device (E;N�D) wes installed: /�-15"�/`f Date this (orm was comFleled:lz-/� 1� <br />Ir,stallation Property O�roner Name and Contacl Info: Scon P, o ev <br />�v.. <br />ProperfyAddmss: liSll V�r��n�a °r:uac�' i,k 4�/ <br />Pre•Installation Inspection Checklist: <br />All items musf be checked'Yes' in order for a BWD to k c conside; ed for installation <br />Is there a basement or level of Ihe house ihat is at or near assumed sew�er main elevalion? [✓]�Yes ❑ No <br />Are there fixlures in the house located below the upslream se����er manhole rim elevation? [�Yes ❑ No <br />Is thP side se�+�er currenlly UNPROTECTED from sev��er backups (does nol have a BWD installed)? �Yes ❑ No <br />Site Inspection Checklist: <br />AII items must be checked'Yes' befo; e inspection is considered compfete <br />Was side sewer N inspected irom buiiding to sewer main? �Yes ❑ No Condition: <br />Does side sewer have at leasi 1% slope fror�i the building to sewer main? T�Yes ❑ No Describe: d�C <br />Have all building sevrer drain connections to the side sewer been identified and locatetl? [j'S'es ❑ No <br />Hzve all property slorm drainage connections to the sid� sewer been identifir;d and located? t[�'Fes ❑ No <br />Has properfy 6een evalualed for drainage deficiencies with 6ndings cor��munir.ated to property otvner? �es ❑ No <br />installation Details: <br />What type and brand of BWD was inslalled at this site (Clean Check BWV, Grinder pump, elc.): /. /rdn �Cl«1� <br />Where was lhe device installed (general descr.ption, ailach map)? /H %ack vf ,�ONSL l.� N6 <br />Was lhere any other sewer or s'orm drainage work completed in conjunclion ��ith the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are ali downspouls and sitz drainage disconnected from upsUeam e` the 13WD? [� Yes ❑ No Commenls: <br />Does BWD posilioning meets minimum slope requirement of >1 %? '[✓�Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance afler loosening thumb screw? �Yes ❑ No <br />Is BIA�D loc4ed into the proper position and thumb scre�v tightened? [� Yes ❑ No <br />Circle the BWD cover. irrigation cover (landscape area) I tra�e load �earing cover (drive sudace) I access hatch (building) <br />/ <br />Was property owner shown the location of ihe insialled dWD? �j Yes ❑ No Commenls: <br />Properly Owner's Signature: � Date: I a' �� I <br />Installer's Signalure: Dale: /Z'/4 /� _ <br />Revision: 2 1 Monday, Septembcr 15, Z014 <br />