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! <br /> � <br /> . gACKWATER �REVEi�TiORi DEVICE FIiVAL ; <br /> E„ lNSTALLATION CHECKLtST ; <br /> , <br /> �t`►ec�n ��F �G � s��de '�e-��', �_ �c , <br /> ���` � .��CS� n,,��� c�� ,���,� �..�;� ! <br /> Instailation Company Name and Contact Info:�r�C,r�ts.��'�4ic� �tt�-�----Ij� , <br /> Date this form was completed:�_ + <br /> Date Backwaler Prevention device(BWD)was installed:��l.� ; <br /> �h�-a����+-rY� as- -r�st I <br /> Installolion Propetty Owner Name and Conlact Info: � <br /> Property Addtess:� F C i <br /> Pre•Installation Inspection Checklist: <br /> All ilems must be checked'Yes'in order for a BWD to be considered for insfalfation ' <br /> Is there a basemenl or level of the house ihat is at or near assumed sewer main elevalicn?�Yes ❑No � <br /> Are there fixlures in ihe house lacaled below the upstream sewer manhole rim elevalion?[�'Yes ❑No ; <br /> Is the side sewer cu«enlly UNPROTECTED irom sewer backups(does not have a BVJD insialled)?[�Yes ❑No i <br /> Site Inspection Checklist: ' <br /> All ilems must be checked'Yes'before inspection is considered compiefe /� / � <br /> l4�as side sevaer TV inspected from building lo se�ver main? �Yes ❑ i:o Condition:C��(�:.1 <br /> Does side sewer have al leasll%slope irom the builtling to sewer main? [�1'es ❑iJu Describe: <br /> Have all building sewer drain connections to the side sewer been identi(ied and located7 �Yes ❑ No ; <br /> Have all property storm drain�ye connections to the side sewer becn idenlilied and focated7 [�"Yes ❑ No ! <br /> Has property been evaluated for drainage deficiencies wilh fintlings commu�iicated lo property owner? �'Yes ❑ No � <br /> Installation Details: � <br /> Whal rype and brand of BWD was installed at this sile(Clean Check BWV,Grinder pumpi etc.):�'�L�� ' <br /> ���������r A�.,�c-l� <br /> Where was Ihe device installed (general description,ailach map)? ���,/Z��C�dC.-�---, � <br /> Was ihete any other se�ver or slorm drainage work completed in conjunctioi w�h llie`1�WD vaoik7 Is so please describe:_ � <br /> --��� <br /> Installatlon Checklist: <br /> Are all downspouls and site tlrainage disconneeted from upstream of lhe BWD? �Yes ❑No Comments: <br /> Does BWD pusilioning meels minimum siope requiremenl of>1%? �Yes ❑No Commenls:_____ _.— <br /> Can BWD be pulled out for inspection and maintenance a(ler loosening Ihumb screw? [�es ❑No <br /> Is DWD locked into 1he pro nrposilion an ihumb screw tighiened? �fes ❑No <br /> Circle Ihe BWD cove�.ungalion cover p dscaoe area)f lratfic load bearing cover(drive suriace)!access ha�ch(building) <br /> Was property ov�ner�sm wn li�ie�o a ion o Ihe in.tal ed BWD? �}Yes ❑ No Commenls: -- <br /> Properly Owner's Signalure:_ _ � Dale:____�Q(�,f'"�(�— <br /> Installers5ignaturc� �ti_ Date:� ��L�C�---- <br /> Revision: 2 J. Priday,Sepicm�er 1J,70]4 <br />