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i <br /> , <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL '; <br /> INSTA,LLATION CHECKLIST <br /> ; <br /> � <br /> � <br /> Ins?allatiun Company Name and�ontact Into: E�ZD .�--vv��Sl�.-�� L�c 2n(n- iaLo - D`i'Z`I' i <br /> Date Backwaler PreveNion device(BWD)was insta!led: Date this(orm was complelecl: � <br /> Inslallation Property O�vner Name and Contact Info: P-C-.I�a w✓-�'1-Snn� � <br /> Property Address: ���4- W L'�'�'+q�'1-' A✓� CVL92L rr ��� ��'� 1 � <br /> Pre-Installation Inspection Checklist: <br /> Al!items must be checked'Yes'in orderl'ora BN/D to be considered for installafion � <br /> Is lhere a basement or Ievei of the house lhat is al or near assumed sewer main elevation?�Yes ❑No ! <br /> Are there fiMures in the house located below the upstream sewer manhole rim elevation?�Yes ❑No � <br /> Is the side sewer currently UNPROTECTE�from sewer backups(does not have a BWD installed)?I�,Yes ❑tJo � <br /> Site Inspection Checklict: ' <br /> i <br /> All ifems must 6e checked'Yes'be(ore inspec(ion is considered complefe � <br /> Was side sewer N inspetied from building to sewer main? �c Yes ❑No Condition:? ' <br /> Does side sewer have at least 1%slope irom the buitding to sewer main? �Yes ❑No Descnbe: ! <br /> Have all building sewer drain connections to the side sewer 6een ident�ed and located? �Yes ❑No ; <br /> Have all property storm drainage connections lo the side sewer been idenlified and located? [�Yes ❑No <br /> i <br /> Has properly been evaluated for drainage de0ciencies with(indings communicated lo property owner? �Yes ❑Mo <br /> Installation Detail8: <br /> What lype and 6rand of 8WD was installed at this site(Clean Check BWV,Grinder pump,etc.):�r�/z h S h,�-�v. i <br /> Where was the device installed(general descripGon,atlach map)? RerK R.o f���.��.�r D�o� iN C��c_rz,;-rc I <br /> Sc•� j <br /> Was ihere any olher sewer or storm drainage work completed in conjunciion with Ihe 8Wb work?Is so please descnbe:_ � <br /> I <br /> i <br /> installation Checklist: <br /> Are all downspouls and sile drainage discannected 1�m upsueam of Ihe BWD? (�Yes [�No Comments: i <br /> � <br /> Does BWD positianing meels minimum slope requirement at>1%? �Yes ❑No Commenis: i <br /> Can BWD be pulled oid Inr inspeclion and maintenance a(ler loosenin9lhumb screw7 (�,Yes ❑No � <br /> Is BWD locked inlo Ihe proper position and thumb screw Gyhte�ed? �],Yes ❑No _ � <br /> Cirr.le Ihe BWD cover:irrigation cover(landscape area)1 traffic load bearing cover jdrive surlace) access halch(building) � <br /> Was property owner shown the location of the instalied BWD7 �Yes ❑No Commenls: � <br /> ; <br /> PropeHy O�mer's Signalure: //���, Date: 2�2Z� �s� ' <br /> Installers Signalure:. �� Date:�. - 2.3 —IS � <br /> Revision: 2 1 7ucsday,Septemher 16, 201 A ' <br /> i <br />