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ILJ�— g � <br /> ,� A(,KWATFR PREVENTION DE�/ICE FINAL <br /> � <br /> o , INSTALLATION CHECKLIST <br /> Inslallation Company Name and Conlact Info: ` �ri� F'�C�L�S �� ��i11 S in�(��J�,( <br /> Date BaokN�ater Prevention de��ice (BWD)was insialled: �1 'ti1--1� P „ZZ_)r-� <br /> � Date this form was ccm leted: <br /> Installalion Properry Owner Name and Conta�t Info:!�, � / • � �� yJs-�59-f?107�yfs?�/y 8l95 <br /> Properly Address: S/� ,�.z..�l�.,.u,� /c,,,�, Y f/�1�9 �f�lV� <br /> Pre•Installation Inspection Checklish <br /> All i�ems musf be checked'Yes'in order(or a BWD lo be Considered lor installation <br /> Is there a 6asement or level oi the house ihal is at or near assumed sewer main elevation?[✓J Yes ❑No <br /> /�re I�here fxtures in ihe house located belo�v Ihe upsheam sewer manhole rim elovation'?[�Yes ❑ N <br /> Is Ihe side sevrer curzer�tly UPJPROTECTED(rom sewer backups (does nol have a BWD installed�? Yes ❑No <br /> Site Inspection Chocklist: <br /> All ilems musf be checked'Yes'be(ae inspection is considered com lelc <br /> Was side sewer 1V inspected from building �o sewer main? es ❑No Condition: <br /> Docs side sewer have al least 1%slope from ihe bu�lding lo sewer main7 �_�es ❑ No U cribe: <br /> Have all buiiding sewer drain connections lo ihe side sewer been identifed and lacaletl? [ Yes ❑ No <br /> Have atl property storm drainage conneclions to the side sev�er been idenlified and located7 ��e> ❑ N <br /> Has properiy been evalualetl for drainage deficiencies wilh tindings communicaied to propsrty oe�ner? [ Yes ❑ No <br /> Installation Details: <br /> 11'hal type am1 brmd of BWD was installed at this s' e(Clean Check B�1N, de;pump,elc.):.____ <br /> Whu�.was Ihe device installe�l eneral descri lion, atlar.h ma � �' � � <br /> (9 P P)�• _ o� r� - a�o.,-� 3-I-u '� <br /> =��Y+'% , S'r��wct �� �.J _ <br /> l'Vas Ihere any olher sev�er or storm drainage work compieted in conjunclion v;ilh Iho[3WD work7 Is so piease describe:�1� <br /> Installalion Checklist: <br /> Are all dovrnspouls and sile tlrainage disconnected from upslream of the B D7 es [) No CommeNs: <br /> Does E3WD pnsitioning mects minimum slope requiremsnl oi>1°/a? Yes ❑No Commenfs: <br /> Can BWD be pullr.d oul(or inspeclion and maintenanr,e after loosening Ihumb s�rew'1 �✓�Yes []No <br /> Is E3WD locked into lho proper position and Ihumb screv�ti hlenetl? �S ❑No <br /> Cirde the IiWD a�ver: irriya(ion cover�c�C�,S(���c load bEa ' g cover(drive surface)1 access hatr,h(building) <br /> UJas properly,�vrrier shown Ihe locatioi of!hc installed DWU? es ❑ No Commenls: <br /> Properiy Owner's Signalure:. , ,���L*� Dale: <br /> �-zz -is <br /> Installer's Signature: l/� ;,�, , � n('�e: •��� /� __— <br /> --�/ 7a.ar- _ - .� <br /> lievi;ion: ? U 1 Monday,Septr.mber l5, 2014 <br />