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BACKWATEFt PREVENTION DEVICE FIF�AL <br />INSTALLATION CHECKLIST <br />Inslallation Company',Vame acd Contact In(o: �-{F_ �c7 P( ,,-...fi, � �c <br />Date Back�vater Prevention device (BWD) was installed: �-2-9- r f Daie this form �;�as completed: `� - 2- �S <br />Installation Property Owner Ne:me and Contact Info: J v L� c- 6� r� � 303- G-7 �co __ <br />Property Address: �-DI C' _ C-7 � S; C-;�Irytr�t-r- wn . �� Zr I _ <br />Pre•Installation Inspection Checklist: <br />�II i;ems must be checked `Yes' in order ior a B'ND tr be considered (orinstallation <br />Is tliere a basement or level o' the house that is at oi near assumed se�ver main alevation %�Yes ❑ No <br />Are there fixtures in tlie house located belorv the upstream se�ver manhole r:m ele��aGon?� Yes [�I No <br />Is the side setver currenU; UNPP,OTECTED from seerer hackups (does nct have a B'ND ir stalledl? J�.Yes ❑ No <br />Site Inspection Checklist: <br />All items must be che�ked 'Yes' neforP inspecricn is considerea complele <br />Was side sev:er N inspecled (rom buiiding to sewer main? �Yes ❑ No Condition: OiL <br />Does side se�ver have at least 1% slope from the builJing to se�,ver main? j�Yes ❑ No Describe: _ <br />Have all building se�n�er drain connections to the side sewer been identified and located? �] Yes ❑ No <br />Have all property storm drainage connec5ons to the side sewer heen iden6fied and locatetl? �Yes ❑ No <br />rlas property been evalualed (or drainage deficiencies ��.�th fnG,ngs communicated to property o�:mer? '�Yes ❑ P:o <br />Installation Details: \ <br />Vdhat type and brand of BWD was installed at ihis site (Clean Check BWV, Grinder pump, e1c.): C-Aai('La5 �3 S) <br />Vdhere �vas the device installed (general description, attach map)? RRSi mtu�T �'C�,�2 �,,, C�,.� c2�rE <br />Was lliere any other sewer or storm drainage �vo�ic completed in conjuncGon with the BWD e,�ork? Is so please descnbe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upsUeam of the BWD? (�Yes ❑ No Comments: <br />Does BNJD positioning meets minimum slope requirement of >1 i6? �Yes ❑ No Comments: <br />Can BVVD be pulled out (or inspection and mainlenance a(ier loosening thumb scre�v? '�Yes ❑ No INDeoL Sc ��-• U Q <br />Is BWD locked into the proper position and thumb s�rew tightened? (�Yes ❑ No <br />Circle the BWD cover: irtigation cover (landscape area)1 tra(fic load bearing cover (drive sudace) access hatc uilding) <br />lNas proper;y owner shown the location of the installed BWD? �Yes ❑ No Comments: <br />Property Ovmer's Signature: .�t�^- V�!.��� Date: � z�' ���� <br />Installer's Signature: V�--����-��� Date: Lj 2��.� <br />acvision: z <br />Tuesday, September 16, 2014 <br />