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G <br />C�� <br />..�BACKViIATER PF:EVENTION DEVtCE FIi�AL <br />1NSTALLATIAIV CHECKLI�I' <br />Instellalion Company Name and CoNaci IMo:�{ <br />Dale Bacla�rater PreveMion device (BWD) wes Inst� <br />Installallon Pmperty O�mer Name and Contact Info: <br />G <br />�ale ihls ionn �vas <br />Propedy Address: - ' _"—' <br />Pre�lnstallotion Inspeciion Checklist: <br />All items must be cltecked Nes'!n oMer for a BLVD fo be considered forinslallaflon <br />Is there a hnsemont or level oi lha house that ie al or mer assumed sewor main alevetion? � Yes ❑ No <br />Ate there Bxtures in Ihe house IocateA betnei Ihe upstream sov:er manhole rim efovalion? �Ycs ❑ No <br />Is tho sitlo sev.�er currentty UNPR01 ECTEO from sewer backups (doos nol havo a BWD installed)7�Yes ❑ No <br />Slle Inspection Checklist: <br />All Items must be checked'Yes' beforo inspection is considored complote ,� I <br />lNas sitlo sawer N Inspecled Irom buildin9lo sec+er main? (�Yes ❑ Wo Cr,idillon: _� Y.KI_- <br />Does side se�vor have ai least t"/o slopa irom lhc building to sewer malnl f�'es ❑ No Describe: <br />Have all bulltling sewer drein connecVons to Ihe Fido se5ver hoen Identiflud n Ir d Incy:<d? �es � No <br />Have all property srorm d�lnegc connections to the alde sev�er Lwn idenUiied and la:atod7 �, � Yes ❑ No <br />C <br />Hos property been ev�luc+tod (or droinl7e deflCiencles wilh fintlings communicated ic� properiy mvnor? �I,Yes ❑ No <br />Installation0�lalls: , � <br />Whal type and br�ntl of BWD e�as instailed at lhls site (Clean Cheek�Gd� pum���� �` + 1, � <br />Where was Iho device inslalled (general d�scriplion, atlach map)7 � <br />Was thcre any other sewor or storm drainagu work completed in con�unr,tion �vllh the BVJD vrorkl Is so ple�ise describe: __ <br />----_____.�(C� - .�.— <br />Inslallation Cher.klist: <br />Are ell dovmspouLs and sile tltalnago d�sconne�ed from upsUeam ot lhu BWD? (�"fes U No Cumntenls: ___. __ <br />�oes BN'U posillonln� meels minlmum slopc requiremenl of >1%7 � Yas � i No Commeniti: __ __.__`_._ <br />Can BWD be pulled oW fur in ;p�cUon anA malnlenance alter lousening Ihumb scraw7 �Yes L� No <br />Is BWD loc'�ced into Ihe proper pasilion and thumb scre�v tighlaned? f y�'es ❑ No <br />Gircle Uie l3WD co r. Irtlgatyfan�over ndscape aroa)! lratfic lo2d beadng onvar (ddve surfam)1 access hatch (bullding) <br />Was prc�arty o�vner s iown Ihe locntion ot thc� Inslalled BWD? �Yes ❑ No Cvmmenls: _ _ __— <br />� C� Dale:_ �s/lf��� — <br />Property Owners Signatum: —. ---,- . � <br />Inslallois9i�nalure:,__ �T� ��-� Oate:.�_�i�.�Q .� _ __ <br />���-/ 1 rridoy, S,�pi+'m6cr 12, ioin <br />RecdSion: 2 <br />