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� BACKWATER PREVENTION DEVICE FINAL <br /> a INSTALLATION CHECKLIST <br /> Installation Company Name and Contact In(o: �l="Yz-� �uw� !31 ni�e LL c� ,�a�� 4b te-o9 29 <br /> Date BacM��ater Prevention device(BWD)�vas installed:S � � �S Date this form was completed: �'-3—1 S <br /> Installation Property Ovmer Name and Contact Info: W�N Ki-^2-- Ce 12— �e3 f r —'Z l '� 3 <br /> PropertyAddress: 1'� 21 C'oL�3�� /¢vrr �11L'�C�l'� wra . 9�Zo � <br /> Pre•Installation Inspection Checkflst: <br /> All ilems must be checked'Yes'in order lor a BWD to be considered tor installafion <br /> Is lhere a basemenl or level of the house that is at or near assumed setiver main elevation7�Yes ❑No <br /> Are there fixtures in the house loraled below the upstream sewer manhole rim etevation7�-Yes ❑No <br /> Is the side se�ver currently UNPROTECTED from searer backups(does not have a 9WD installed)?'�.Yes ❑�o <br /> Site Inspection Checklist: <br /> All rtems must be cher.ked'Yes'6e(ore inspection is considered compfete `� <br /> N'as side setiver N inspected from huilding to sewer main7 �Yes ❑No Condition: 6 l� �Co'-'���'�/ <br /> Does side sewer have at least 1°i, clnne from ihe building to sewer main7 �Yes ❑ No Describe: <br /> Have all building sevaer drain connections to the side sewer been idenlified and loeafed? �Yes ❑No <br /> Have all property storm drainage eonneetions to 1he side sewer been identified and located? �Yes ❑No I <br /> Has property been evaluated for drainaae defieiencies with findings communicaletl to property o�vner? �Yes ❑ No I <br /> Installation Details: <br /> 1Nhat rype and brand oi BN�D was installed at ihis site heck BNN,Grinder pump,elc.): e L_t�9 tiJ C',��rC,l� <br /> Whero�vas the device installed(general descripti ,attaeh map)? <br /> � <br /> UVas there any olher sev+er or storm drainage work completed in conjunction with the BWD work7 Is so please descdbe:�� <br /> Installation Checklist: <br /> Are all doanspouts and site drainage disconnecled hom upslream of Ihe BWD? �Yes ❑No Comments: <br /> Does BWD posAioning meets minimum slope requirement of>1%? �Yes ❑�o Comments: <br /> Can BIND be pulled out for inspection and maintenance aher loosening ihumb screw? �Yes ❑No <br /> Is 81ND locked inlo the r osil n and thumb screw Gghtened? �Yes ❑No <br /> Circle the BWD cov r.irnga6on r(landscape�area)!trattic load bearing cover(drive sudace)1 access hatch(building) <br /> Was property owner s own e lo ti o he i SI led BWD? �Yes ❑No Comments: <br /> Property Ownei s Signature: Dale: � � �� � <br /> Installer's Signature: �.�-�--� Date: .�'�—3 � �'� <br /> Revision: 2 1 Tuesday,September 16, 201A <br />