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BA�KWATER PREVENTiON DEVICE FlNAL <br />INSTALLATION CHECKLIST <br />Insla!iation Company Name and Confact In(o: <br />Dal° Backwaler Prevenlion device (B4VD) aras instailed: �� Z I� Dale this fcrm was completed� � I�� I 5 <br />Inslallalion Property O�.vner Name and Conlact Info: � T1- ' <br />���-'��, )l .��w� r , <br />ProperfyAddress: �-5�� �J�../�,,.f ��,�f-f- (�� ��,?�>/ <br />Pre•Installation Inspection Checklist: <br />Af! ilems musf be chec4ed 'Yes' in order (or a& WD fo be consrdeiea tar installatron <br />Is Ihere a basemenl or level oi the house th2t is at or near assumed sewer main elevaficn? � yes �,�o <br />Are there fixtures in the house located below the upslream sewer manhole rim elevation? [f Yes ❑ No • <br />Is Ilie side sevrer currently UNPROTECTED from se�a�er backups (does not have a 8V1'D inslalled)? (' Yes [] No <br />Site Inspection Checklist: <br />All items musl 6e checked 'Yes' 6efore insoeclion is considered c plefe <br />�Vas side sewer N inspected from buiiding to se�a�er main? (�es ❑ No kOndition: <br />Does side sev;er h�ve af leasi 1 �o slope (rom the building lo setiver ma n? [�Yes ❑ �'o Descrihe: <br />Nave all building sewer dr�in co��nectic�s lo ihe sid� see;er been idenlified and lo�a'ed? �Yes .� No <br />Hzve ail propeny storm drainage connections lo Ihe side sewer heen identified and Iccafed? [jYes ❑,yo <br />Has property been ovaivated for drainage deficiencies �vith lindings communicated lo property ovmer? (� Yes No <br />�_� <br />Installation Details: <br />^�� � �. <br />V1�hzl tyu�� and brand o( [�4V0 was insialled al this siEe�Clean Check BNN, Qrinder pump, elc.): ���� �: <br />'Plhere v+as Iha dewr.e inslalled (general descriplio , atlach map)'? �. �; ,� :� `�,� , <br />�,� � �[- F ti' <br />_L.'� � ?-- .1'�!_>_CJ.Ynni..rr- i-I��en�� �'" — <br />Was fhere any other se�eer or storm dranage �vork ccmpleled in conjunc�ion with ihe E�WD w�rk? Is so piease descnbe. ���C� <br />Installation Checklist: <br />A'�' a�� dov+nspeu(s and site draina,yr, disconnectetl from upslream o( Ihe B D? <br />Uoes db'1D <br />--- i _ <br />['� Yes ❑ No Commenls: <br />p��s�Ucning meels mirnmum slope requiremenl of >t°6? [ Ycs ❑ No Com�uenls: <br />Can BWD be pulled out for inspecfion a�d maintenance afler loosening Ihu ib sae�v9 [�es ❑ No <br />Is BWU locketl into the preper pcsitinn and thumb.screw Iighlened? i Yes ❑ No <br />Grcle lhr. 81h�� cover: imga io r�`4e� (lan�s��i�rea} / iraffic load 6eaJing cover (drive suriaee) / access hatch (building) <br />b,'as property nwner shown !he localibn ol tho inslalied BWD? ,_ Yes ❑ No Comments: <br />Property O�vner's <br />Inslaller's Signa(ure: <br />Revision: ! <br />i/� ' I�' <br />� <br />�_ , <br />' � I _ Dafe; i / �- ; �j <br />��'� Dale: �r ��__ <br />Mundav. Srnf�r,.ti,,. , r ,,... <br />