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BA�KWp►TER PREVENTI�N DEVICE FINAL <br />INSTALLAT(4N �HEGKL.IST <br />lnstallation Campany Name and Contact info: i�n ��1v ������ �`'� <br />Date Bac4cwater Prevention device (BWD) was ins�alfed: 5�� -�� S� _ Date this form was completed:_�- (o� l 5� <br />insta](aiion Pro�e�ty Owner Name and Con�act Info: 'L.a�fG S�-�,.�t�.� <br />Properly Address, _ t �� t t-c,�,,,,h� r�Q �-v � r� ����.�•s A���� i� <br />Pre-lnstallation lnspecition Checkiis#: <br />A11 items musf be checked `Yes' in order for a B WD fo be consJder�d for instalJation <br />Is ti�ere a basement or levef af the hause that 'rs at or near assumed sewer main elevation? [� Yes � No <br />Are fhere fxtures in the house located below the upsfream sewer manhole rim elevation? �] Yes ❑ Na <br />Is the side sewer cu�rently UNPR�TECTED from sewer backups (does not have a BWD �nstalletl}?� Yes ❑ No <br />Si�e inspecfian Checklisi: <br />A!! ifems must be checked `Yes' before �nspecfion is consrdered comptefe <br />Was side sewer N inspected from building to sewer main? �] Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? � Yes ❑ Na Describe: <br />Have ail building sewer drain connections to the side sewer beert identified antl iocated? ,�] Yes ❑ No <br />Have all property storm drainage connections to the side sewer been iden '�f'ied and locafed? [� Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings cammunicated to proper(y owner? [� Yes ❑ No <br />Instalfation Details: , <br />Wha# #ype and brand of BVIIQ was installed at this si#e GEean Check BWV, rinder pump, etc.): <br />1Nhere was the device installed {general description, attach map . ��- S i r� ��� ��P t,� �-✓ <br />�� �� <br />_��, <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD wor[c? ls so please descrbe: ,s, <br />C� <br />Insfallatian Checklist: <br />Are a�i dawnspouts and site drainage dlsconnected from upstream of fhe SIND? � Yes ❑ Ho Cammen�s: <br />Does 8WD positioning meeis minimum sEope r2quirement of >1 %? � Yes ❑ No Camments: <br />Can BWD be pulled out for inspection and maintenance a�er {oosening �humb screw? �] Yes ❑ No <br />Is 8WD locked inta the proper.pos+�io�-arrd�Fr - crew tightenad? LI Yes ❑ No <br />Circle ihe BWD cov : imgation cover (landscape area traf�c load bearing cover (drive surface} I access hatch (buildingj <br />Was property owner sho ' stalled 8WD? � Yes ❑ No Commen#s: <br />Property Owner's Signature: _ Date; <br />Installers Signature: aa�e: ��- �' � �� <br />Revision: 2 —� 1 friday, September 12, Z014 <br />