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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: APo/io ��N�Mi�i�'+4 (�/a�) 3�s7� �.SG7 <br /> Date Back�vater Prevention device(BWD)was installed:)1l l�Date ihis form was completed: / l /t <br /> Installation Property Owner Name and Contact In(o:„j'��•� ��u np.����/�t� �S�� 1 ff3% <br /> PropertyAddress: J/GC 2u�Xe� AvG �ve�el� wp ���� <br /> Pre-Instailation Inspection Checklist: <br /> All ifems must 6e checked'Yes'in orde�lor a 8WD fo be considered/or installation <br /> Is there a basement or level of lhe house tFat is al or near assumed sewer main elevation?(L�Yes ❑No <br /> Are there fixtures in the house localed below the upstream sewer manhole rim elevalion?�Yes ❑No <br /> Is the side sewer currenUy UNPROTECTED Gom sewer backups(does not have a BWD inslalled)?�Yes ❑No <br /> Site Inspeetion Checklist: <br /> All items must be checked'Yes'6efore inspecG'on is considered complete ' <br /> Was side sewer N inspec!ed from building to sewer main? [�Yes ❑No Condition: �ni�w <br /> Does side sewer have at leas! �%slope from ihe building to sewer mainl (�Yes ❑No �escribe: %y �ii��fi <br /> Have aIl building sewer drain conneclions to the side sewer been identified and located? [�Yes ❑No i <br /> Have all property storm drainage connections ro ihe side sewer been identif ed and located? �Yes ❑ No i <br /> Has properly been evaluated(or drainage deficiencies with findings communicated lo property ov��er? �Ves ❑No <br /> InstallaUon Detalls: <br /> Whal type and brand ot BWD was installed at this site(Clean Check BWV,Grinder pump,elc.):�Ita.� �lo eGN <br /> Where was the device installed(general descriplion,attach map)? .✓�--�a b weS� �/.�P� o�F � <br /> �he s,�c o�(r lvyatr i�iJ�ve�en hriwf� i n O Dr+v�.vc.��. <br /> Was ihere an�olher sewer or storm drainage work compleled in conjunction wi�h the BN'D work?Is so please descnbe:_ � <br /> !7lSLGn - �� O� !70'�//'� SPUu'; <br /> -T <br /> Installation Checklist: <br /> Are all downspouts and sile drainage disconnected from upslream of the BWD1 [�Yes ❑No Comments: <br /> Does BWD posilioniny meels minimum slope requirement o(>1%? �Yes ❑No Comments: �_ <br /> Can BWD be pulled out for inspeclion and mainlenance after loosening thumb screw? �Yes ❑No <br /> Is BWD locked into lhe proper position and thumb screw tightened? �Yes ❑No <br /> Cirde ihe BWD cov�rt ngalion cover(landsca e ar ' I tra!�ic load bearing cover(drive surface)1 access hatch(building) <br /> � <br /> Was properly owner sho�vn the location of the instal!ed BWD? �Yes ❑No Comments: <br /> Property O�mer's Signalure: - � '�--��/`�'"U � Date:�_1_� �'L <br /> Installar's Signatur • Date:_� /fL��� <br /> Revision:2 1 Friday,Septembcr 12,2014 <br />