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�� <br /> . BACKWAti ER PREVEN7�ON DEVICE FINAL <br /> IN�TALLATION CHECKLIS7 <br /> • s:a!latcn Cor�p�ry �vame and Conlact Into riQ'4�'�P�f'L�-1S i'L�wlgl/11C��� �nl< <'� 2.5-zSQ,�3�y <br /> Dale Back�aater Prevention device (BVJD)a+as inslalfed: IZ �'I I Dafe ihis form;bas completed: I�-- �- ��� <br /> I � <br /> Inslal�ation Propery O:vner Name and Contact Info:�JSA- rv 50�0�� �I'S���715 �- � (ol S <br /> Proper;y A�ddress: _�� I O� ��,�= 5 I. � ��'���� u-A -�L�Z�I I <br /> . <br /> Pre•Installation Inspeetion Checklist: � <br /> l,ii+;�ms rnusl be checked 'Yes'in order(or a BWD to Ge considered/or insfalla�ion <br /> Is Ihzre a basemen;or;evel of Iha house;hat is at or r,ear assumetl se�.v2r main e; n7 ; es C ^l� <br /> Are th�re fix.�ures in the house lo�ated ba(o�,��the upslream sewer manhole rim eleva;:� �7�s ❑ iJc <br />� Is �he sde see;er cu�ren±ly UNPROTECTED irom se�ver backups (does no;have a BWO ��istaue�i% �_, res ; ] ho <br /> Si e Ins ection Checklist: <br /> t p <br /> All ifems must be checked 'Yes'before inspec;ion is considered complefe <br /> lNas side se��.er N inspected !rom huilding to see�er maln? es ❑ No Condilion �� <br /> Does side sev�er have at least 1°�o s!ope irom the building to sevrer main7 [-�-Ye.s ❑ N� Describe <br /> Ha:e all ouilding se,ver drain cornections (o the side sev;er been identi(ied and localed? 'es ❑ �do <br /> Have all propeny sterm drainage conneefions to the side se�:�er b�?n idenlified and located? �'�s ❑ IJo <br /> Nas property been evaluated for drainage deficiencies e✓ith findings communicated to property owner? ��s ❑ No <br /> Instailatfon Detail.=: � <br /> 11'hat l7Pe ond b�and oi BWD tivas inslalled at this sile(Clean Check BNN, Grinder pump,e}c.). � �F�''� L�-lL <br /> N�h,�re ti;as ihe device inslalled (general descriotion, attach map)? yViA� 1°s`TZ'�e�'4��1 <br /> t1�as Ihere any other se�ver or slorm drainage work completed in conjuncuon witn tho BUVD Work? Is sn please describe ti� <br /> i <br /> Installation Checklist: I <br /> A�e c�l'� d�rr+nspouts and site drainage d�sconnec(ed (rom upsiream o(Ihe BWD? ' Yes _] No Commen�s: <br /> Coes BI��D posilioning meets minimum slope requiremenl ot>1 io? �s ❑ No Co�mments ___ <br /> Can BtiVD be pulled out for inspection and maintenance after loosening Ihurnb screv�? �s ❑ ��!o <br /> i <br /> Is BWD lor,ked into the pro ;r_n �sitioo and In��m �s e�.v;iyhlened? es ❑ !Jo � <br /> Circle the BWD covec i igation cover(landscape area ira(fic load bearing cove� (drive su�(ace)/access ha:ch ;bui�dina; <br /> 4Vas property owner shown ihe loca(ion o(lhe inslatled BVVD? �es ❑ No Commeh�s: <br /> I <br /> � n i• <br /> Propeny�O�vner's Signawre: U' �� Dale: : ����/�� <br /> Inslaller's Signalure: Dale: I��—�O— <br /> . — � �--- <br /> Rewsion�. 2 1 Monday, Sept��m6er 75, 20I.4 <br />