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i <br /> BA'CKWATER PRLVENTION DEVICE FINAL <br /> r INSTALLATIOf�➢ CHECKLIST <br /> I <br /> inslallalinn Company Name and Coniact Info: l,, iv1 �`('y�LL�SI �L � � <br /> .n��r5 i�r-,�jN r <br /> Date Dackwaler Prevontion device (BWD)was inslalled:����Date this form v�as compleled:—`�5 <br /> Insiallation Froperty Owner Name and Conlacl Info:[n n�T� ��� <br /> Property Adtlress:�! �(__�,J�n.�.��_�,� �V,�. �. I. ' <br /> � �'--�4----- <br /> Pre•Instaliation Inspection ChecklisL' � <br /> All items must be checked'Yes'in oider(or a BIND to be considered(or,instnllalion <br /> Is there a basemant or level oCihe housc that is at or nea;assumed se�yer main clevation7[�s ❑No <br /> Are Ihere fixtures in ihe huuse ior,�ted belo�v ihe upslream sewer manhol�rim elevation?(�J�Yes ❑No <br /> IS(hB 51(I(�SClh�er cunenlly UNPROTEGTED(rom sewer backups (does�ot have a BWD installed)?Ci�Yes �� No <br /> Site hispection Checklist: j <br /> I <br /> All items must be checked'Yes'before insper.lion is considered com � �; <br /> VJas side sewer TV inspected irom building to se�,vcr main? _ Yes �� No Contlition: <br /> Does side sewer have at least 1%slope from the building to sewer main�? �]Yes ❑ No DPscrihe: <br /> Have all huilding sewer drain�unneclions lo Ihe side sewer been identifi�Id an 'lec��ted? [�s � � No <br /> Have all propr.rty slorm drainage connec,ions to Ihe side sewer been idc�ntifed and located? Yes � <br /> hlas prnperty been evaivatcd for drainage deficiencies�vilh findings com unicaMd fo property owner? Yes ❑No <br /> Installation Details: � <br /> lNhat type and brand o(f3WD was inslalled�1 this sife(Clcan Check BVJN, Grinder pump, elc.):�'�., er,�=� <br /> N'her1e-w�as(he tlevir,r. inslalled (gr.neral de;criplion, altach map)'� _����_ Ncr.� ��� �,,, �_`� <br /> rwY.r4 _ _____��-___ � <br /> VJa;lhere any ofher sewer or slorm drainage work cnmpleted in conjwir��ioi� i wilh tlie pWp woik7 Is so please de,cribr,:/V 0 <br /> Installation ChecklisL• ; <br /> Are all dovrc,poul>and sile drainage disconnected from upsUeam ol the� JD? [ Yes ❑No Commenls:____ <br /> Daes f3VJD pusilioning meels minimum slope requiremenl ol>1%? �_ Yes � � IJo C�16nIs: ____ __�_ <br /> Can HINU he pulled oul for insper,tion and mainlenance alter lonsening I m crew? [ Ycs ❑ No <br /> Is f3WD locked inlo Ihe proper position and thumb screw fightr,ned? [ Yes (-� No <br /> Cur.le Ihr. BWD cover: ir '_ ���,•fl:�ri;soape area)llrn(fc Io��aring cover(drive surface)1 ar,cess halch(building) <br /> Was properly otvner siioti��ilie'ocal n o�e insl;illed [3WD? ' <br /> J Yes �C�No Commenls�_ T___ <br /> Properfy Ov,�ner's Signalure:�l-(.Q/�� _ __ _ Dale:_ . , ' <br /> y__8�zDi�� - <br /> Inslallcr's Siyna(ure �/�„�,,,s� ,, _ �y � Dat�. � <br /> > �-- -�'���oG.s_ <br /> it�,��s���,�.� � �� — <br /> � A4onday, Sr�Nrm n�r ]5 201� <br /> � <br />