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� l ,� <br />BACKWATER PREVENTION DEVICE FINAL <br />, _.,� <br />INSTALLATION CHECKLIST <br />, <br />Ir�siai�ation Company Name and Conlac! In1o, __ �+\�1� <br />Dats Bac'�c�vater P�evention device ;BWD) was installed <br />'.1:i <br />Ins!a'lalion Property Owner Namo �nd Contacl Inio: jL <br />I'r;;rerf; A9dress _z�(:�l t% l e G� i r�rl A� <br />Pre•Installation inspection Chacklist: <br />Li.'S ('ii.U��1��iN�� . �rJ�. "425-L�,a-�X`iN <br />Date this fcrm vras compla:ed � l l�' <br />i , u � c � �:n � �a�«.P <br />Ail d2ms musl oe checked 'Yes' in oraerinr a 8WD to be considered fa installetion <br />I� ihere a basement or ievel of the house thal is al or r.ear ossumod selver main elevation? �� Yes ❑ Kc <br />i��e !nere fixures in the house located below the upstream sewer mantiole rim elevation? �J Yes ❑ No <br />Is Irs s je se�•rer cmec:'y� JIJPROTE�:TEL' Irom se�ver backups (dees not have a BWD Ins;alled)? �s ❑ iti'c <br />Site Inspeclian Checklist: <br />'" �AIL��ams rnus! bo cher.;ed 'Yes' belore +nspecl;on is consi0ered Cempl i fe <br />\Yas side sewer P,� inspected from build!ng to sewer main? � Yes ,[; No C/ondition. <br />Cces side sewor have at least 14'o slope (rom ihe building to se�ver main7 B'Y�s ❑ No Dc�s Ihe: <br />Have all buildmg sewer dr �i� r,onnections lo ihe side sev;er heen idenl <br />Have all p;oper�y storm drainage connections to the side sev:er been i <br />Has nrope7y Ceen eva ualed for drainaoe deficiencies wilh findings co <br />Installalion Dntails: <br />l'� hat type and 6rand of 6WD was insialled at lhis site (Clean Check <br />15'h�are �vas �he device ins�al'ed (general descrip�inn, atlach map)? _ <br />IVas Ihere any other sewer or stonn drainage wo�k completed m <br />and located? � es ❑ No <br />ied and lo�aied? �es ❑ No <br />nicated to property ov+ner? es ❑ No <br />N, Gnnder purnp, etc.): C l�Po"� C. l�t-Cl� ' <br />n��'� �J _ <br />�vith the DWD e�ork'? Is so p'ease descriUe!�1� <br />Installation Cho�klisL• <br />Arn �II dor�nspouls and sile drainagn disconne�ted from upslroam of Uio E3WD? _ es (] No Commenis. ,___ ._ <br />i)r,es EIWD positioning mecis rninimum slnpe reqwremeni o�>1"07 j. • e5 � � No GommeAls: __________ <br />Ca�i BN�[l l�e pullcd out for �nspection and maintenance afler loosenin� lhumh scree�? � es ❑ No <br />Is B1�VD locked into the pruper �os ' and l � scrow lighlenetl? �es ❑ No <br />Circle the BN�D covec i ngation wver (Iandscape area I Iraffir, load be�a 'nr cover (dnve suiTace) I access hafch (buildiny) <br />';Vas property ow�er sho�vn Ihe IocaGon of t�f r� installed BWD? Ye� ❑ No Comments: <br />C� Prupeiy Owner's.Signaf��/S� � Dale �� �I� <br />� � <br />1 InstaVer's Signature: �z�� ;��l� Dale: _ `Z- � Z / � <br />, <br />Nev�sinnr. 1 Monday, Septem6er 15; 201� <br />