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� �� <br /> BACKWATER PRE!/ENTION DEVICE FINAL <br /> INSTALLRTiON CHECKLIST <br /> Installation Com�any Name and Contact Info: 9 i�o��U �'�u�+�,��� <br /> Date 8aclnvater Prevenlion deviee(BWDj was installed: 3�/���� Date this form was complete�i ' / /� <br /> Installalion Property Owner Name and Contast Infc: •���� � P/ Hu.>n � �Z�61 ��z — �i'��G <br /> Property Address: ��9 �//sy r� <br /> Pre•Installation Inspeclion Checklisl: <br /> All items must 6e checked'Yes'in order lor a BWD to be considered(orinsfallation <br /> Is there a basement or level of the house that is at or near assumed see�er main elevation?�Yes ❑ No <br /> Are there fi�ures in the house localed below lhe upstream sewer manhole rim elevalion?�Yes ❑ No <br /> Is lhe side sewer currenlly UNPROTECTED from sev�er backups(does not have a BWD installed)?�Yes ❑ No <br /> Site Inspecllon Checklist: <br /> All items must 6e checked'Yes'6e(ore inspecfion is:e;isidered complefe <br /> Was side sevrer N inspected irom building to sewer main? �Yes ❑ No Condilion: <br /> Does side se�ver have at least 1% slope(rom the building to sewer main? �Yes ❑ No Describe: <br /> Have all building sewer drain connectiens lo ihe side sea�er been identified and located? �Yes ❑ No <br /> Have all property storm drainage cannections lo the side sewer been identified and Iocated? �Yes ❑ No <br /> Has property been evalualed(or drainage deficiencies wilh�ndings communicated to properly ovme�? �[/]Yes ❑ No <br /> Installation Detalls: <br /> What type and brand oi B'ND was installed at this siJ ean Check BWV�' rinder pump,etc.): <br /> �— y �6F <br /> Where was the device inslalled (general descriplion,aftach map)? �i��s bo�,7 n�v h <br /> I ! J � <br /> ���1` {�L!J � <br /> Was iher2 any other sewer or storm drainage work completed in conjunction with ihe BWD�vo�:?Is so please describe:_ <br /> N� <br /> Installation Checklist: <br /> Are all downspouls and sile drainage disconnected from upslream of ihe BWD�? {(�Yes ❑ No Commenls: <br /> Does BWD posi6oning meets minimum slope requirement o(>t%1 �Yes U No Comments: <br /> Can BWD be pulled out for ir�spec6on antl R�aintenance after loosening ihumb screw? �Yes ❑No <br /> Is �WD locked into lhe proper posi�ion and thumb screw lightened? �Yes ❑ No <br /> Circle the BWD cover: irrigaGon cover(landscape area)!VaKc load beanng cover(drive suriace ccess hatch (buildin <br /> Was property owner shown ihe localion of the installed BWD? �Yes ❑No Commenis: <br /> , <br /> � �//7//.f <br /> Properry Owners Signature• � Date: <br /> Inslaller's Signatur - Date: ������5 <br /> Revision:2 1 Friday,Septemher 12, 2014 <br />