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BACKWATER PREVENT�ION DEVICF_ FINAL <br />INSTALLATiON CHECKLIST <br />r�I:il�aFa��CoT��.�•i�:hl�arn�andCcnf:�cll�it:� _�rV�'�"1r'htLL� � �- �n�i �� �; ,. <br />',at� packwa(er ?revention device (BVdD) �vas inslalle/d�: 3� �1LS _ Date Inis form vras cemp!eted: �' ,:.,��4�� �5 <br />I� ;,ril!ation Properiy Oaner Nanie and Contact Info 1�1�w E��c;,__ �-I25=�Sz � 4�5_4��� ______. _ <br />i'�,�^ry�dd�ess 23u��i� �.,s��l'�r�.-_-i�'_.y1s 5���'1---- — <br />Pr. •Installation Inspection Checklist: <br />�i �tems musf �e chur.ke� '1'n,s' in r^der !a a BbVD to be consrdereo /or instalfahon � <br />„ I,�,ere a hasement or level of the house Ihat is at cr near assumed se�ver main elevation? �'-.,�"Si 'es ❑'�.� <br />�-,c !here fxlures ia the house located te'�o�.v !re ,:pslream s�r:er manho!e rm elc��anon� (-rYes ❑ No <br />�_ '�ie;ide sc:�;er currr.ntly UNPROTEGi� D ho�c se:.er baci�;ps ;do=s n�.�t �;�ve � B',:':) �nsal ed� %`�_ 1'es ,__i ��:: <br />Site Inspection Checklist: <br />.:�. fr@r7ij fll�$i f1:.' Gl'BCn�C ���8 i� hPl^,'d :PSi1�C��:l.'�, IS f' �1tilCtibii i:Cy71U���L' <br />d�, side se;+er 1V �nspec!ed fra^� Lwidr•g to se:ver T�aln? �Yes � I��o Condi!ion: ____ ___. <br />f'c�s side sewer have at leasi 19; slope from lhe building lo sewe� n-s,�n? ��] ves ❑ No D�escnbe: __ ___ <br />�;,:v� atl build�ng sewer drain connections to Ihe side se�ver been i�erL(ied and located? [�.fl`es U No <br />/ <br />i;r;e ail property slorm drainage connections to the side seraer been identi6ed 2nd localed? [ijYes ❑� t��o . <br />!�:�; property been evaluated for dra�nage deficir.ncies with findin.�s communicated lo property owner7 �J'Yes �� fJ, <br />Installation Details: <br />;��a! typ. ard �rand of fiWD �vas inslalled at this site (Clean Check H11N. Grinc:e' pump. elc.): _ �lPwn el.col�__ <br />.'. �c re v.as ihe device �nstalled (general description, altach map)7 __�aok _ avc��___ __ ___ __ <br />y- <br />i:�s there any other se�ver ar storm dram.�ge v:ork completed in con�unchon with ehe l3WD wnrk7 Is so please desr.rihe: <br />Installation Checklist <br />e aV doe,n,F•ouls and ;ite drainage discannecled (rom upslream of tfie OW07 ��}'Sfes �J No Commenfs <br />J� rs 1311'D posilioning meels minimum slope requirement of >i`�:7 ��es (_� No Commenls� ____ __ ___. ___ <br />��;;n B�VD be pul!ed oul for inspeclion and maintenance alter luc��•nir�g ihumb screw� �es ❑ Nu <br />I i3WU locked inlo lhe proper position and �huinb screvr tiyhicnee'? �es ❑ No <br />Ci�cle Ihe DWD cover irngation co:�er (lanrscap� arr.a) ! ir;i`f.c loa �ariny cover (.drive surface) l access halch (budd�nql <br />��'di13 �)f0�)L'f�Y OYJ(10f SIl0;V11 i�l!� �UC;i;I:'.!1 U� ;�10 �I15';7',IC:J 3�:'V�.)�? ✓� YL'S ; _ ; i�0 LOff1f11Cf115: ____ _ ._______ <br />�'�operty0w,ner's5iynalure _ _.� - '� - -- Date.m[j�.(J,-� - �e.�-�} - <br />� � �"1�-___. _ <br />�nslaller's Signature � ;��5• r ft���------ Datr _ '3 ! (o -�-- - - <br />� <br />��:ivnn <br />f�Aonn;il', ti��pt��ci;�rr : �. ?Q1 �l <br />