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i <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL ' i <br /> � <br /> INSTALLATION CHECKLIST J <br /> , � � <br /> , � <br /> Inslaliation Company Name and Contacl Inio:r�c�u"� �oJM a� .�'��^ ��" y� -�//93 � <br /> Date Backwater Prevention device(BN�D)was inslalled: q'Z'��/S Date Ihis form was�ompleted:�`���/S � <br /> Installalion Property Oivner Name and Contact Info: t�yCt�l WIY!/v� ��25 .3� �S'�3 _ i <br /> PropertyAdtlress: ��� �����ov�� f�� � <br /> i <br /> Pre•Installation Inspection Checklist: � <br /> All ilems must be checked'Yes'in order lor a BWD to be cronsidered tor installafion \ � <br /> Is titere a basement or level of the house that is at ur near assurr�ed sewer main elevation? �l 1(es ❑�o : <br /> dre Ihere fixtures in the housa located below Uie upsiream sea�er manhole rim elevalion?�Yes ❑No ! <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD inslalled)7�Yes ❑No � <br /> I <br /> Site Inspection Cheeklist: � <br /> All ifems mus(be checked'Yes'before inspection is considered complete . _ �1 i <br /> Wai side sewer 1V inspected trom building to sewer main? �1'es ❑N Condilion: ��� �S iN �'� C�i'��/i�.� ; <br /> Does side sev�er have at least 1%slope from(he building to sewer main7 Yes ❑N�o ,4escribe: � <br /> Have all bullding sewer drain connections to ihe side sewer been idenlified and located? ��-"Ye ❑ No `� ` <br /> Flave all property Storm drainage conneclions to Ihe side sewer been identified and locatetl7 �Yes ❑Mo � <br /> Has property been evaluaie:for drainage deficiencies titi�ilh findings communicated lo property owner7 �Yes ❑ No i <br /> Installation betails: ' <br /> !Nhal type antl brand of BWD m�as inslalled at this site lean Check WV,Grinder pump,etc.): �e�= of;�c� � <br /> j <br /> Where was the device installed(general descriplion, allac map)? ' ��� it U • u� e� _ + <br /> as ihoro a y Iher sower or slorm drainage work compleled in wnjunclion wilh Ihe E3WD�ti�ork9 Is so please describe: �� i <br /> �SI. � • � ��/r'�S (� i <br /> Installalion Checkiist: � <br /> Are all downspouls and site drainage disconnected from upstream of�t�hJe BUV�9 �f Yes ❑No Commenis � <br /> Does DWD positioning meets minimum slope requiremenl of>1%? M Yes ❑ No C rnmenls: � <br /> Can BIND be pulled oul for inspection and mainlenance after looseniii�umb scre�v? �Yes ❑No � <br /> I <br /> Is BWD lor.ked in(o t.ie proper nosition 2ntl ihumb screw tighfened? � Yes ❑No � <br /> Cirr.le the BVUD cover: �rrigation cov tantlscape area I ir�ffic lo�d bearing covei (drive sudace)1 access hatch (Uuilding) ; <br /> Was property owner shoam the location of Ihe installed BWD? �J Yes ❑No Comments: � <br /> � <br /> I <br /> Property Owner's Signalu^ : ___ Date:�I�� j <br /> hislaller's Signalure�� �� ��'�� i _, Da1e: �t' I�'� j <br /> I <br /> Revision: 2 1 Monday,September]5,7.014 I <br /> I <br /> f <br />