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i <br /> '� BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> ! .� <br /> � <br /> Inslalialion Company Name and Coniact Info:��t� i�r�j�Ll.'S L�vr11 i511L�� �N ( . <br /> Da!e eackwater f'revention device (BWD)�vas inslalled: �i'Z5 ��S Date l�:is form�+��as completed� �7 `� � <br /> Installalion Pioperry Ov,ner Name and Cont�ct Info: _ . �o.-. Z-ll,'c _ <br /> Prope�tyAddress: ��? 7 /➢�;k-< /�...�� F��-<-ff �,�!} y�Z_c;! _ <br /> Pre-Installation Inspection Checklist: <br /> Ail items musf be checkad'Yes'in order for a BWD to t;r, r.onsldered tor installation <br /> i <br /> Is there a basement or level of the house thal is al or nezr assumed se�,ver main elevafion? Yes ❑ �o <br /> Are there fixlures in the house located b�low lhe upstream sev;er manho'e rim elovation" Yes ❑ No <br /> is the side se�,ver currenUy UNPROTECTED irom se�ver backups (does not have a 84VD installed)? �� '] No � <br /> 5ite Inspectian Checklist: <br /> I <br /> I <br /> AO iirms musi 6�crec�:ed 'Yes'be;ore i,nspection is ccnsidered co�tplete <br /> � ��t v � <br /> VJas side sevier 1V inspecied frem building lo sewer main? [�Yes ❑ No Conditicn: " _ ___ I <br /> Docs side seti:�er iave al Icasl 1%slope from ihe buildina to sewer rrain? [�es ❑No Oescribe <br /> Have all 6�i�ding sew�er�rain connzctions to the side sewer been identi ied and Iccaled? �{�'Yes/[] No <br /> Hava all prcoer,y storm drainage connections to the side sewer 6een identified and located? [�'Yes ❑ No ! <br /> Nas property bee� eva!uat2d ier drainage ceFiciencies wilh 6ndings communicated to preperty owner? �Yes ❑ No i <br /> Instailation Details: <br /> I <br /> L�Jhat type aiid brand o(6�1'D was installed at ihis site(Ciean Cneck BI�N/,Grinder pump, etc.): L �'`"' G�l�-- _ <br /> ;Nhere���as llie devi;;e installed (general descnption, 2ftach map)? _4±�L�a-� (R'[1 At,�r� <br /> � <br /> VJas there any atner se,ver er storm drainaye �a�ork completed in conjunction with the E3N�D ��+ork?Is so please descr�b�(J� <br /> I <br /> Installation Checklist: <br /> Are all downspouts and sife dr2inage disconnec�ed from upsiream of ihe BUVD? [�'�fes ❑ No Commenls: <br /> Does QWD plositioning meels minimum slope requiremeN of>19�7 [�s ❑ No Camn Ms: ___ <br /> Can BWD beI pulled out(or inspeclion and maintenance a(ter loosening ihumb screw? es ❑ No <br /> Is 8WD locked into 1 Ei<ula�nd lhumb scruw lighlened? ��es [] No <br /> Circle ihe H1ND cnver. ���n cover(la tlscape area)!Iraffc load bearing cover (drive suriace)f access hatch(building) <br /> 4Vas properiy orrner shown 1he location of the installed BN!D? _, es ❑ No Commenis: <br /> Properiy Or�ner's Sioneture: �s� Date: c��LS �l S <br /> i r��7 S= <br /> Insialler's Slc�nafure: �� % ��_ Date: �- Z� ' <br /> /� — <br /> Revision: 2 � 1 Monday, Scptember 75, 2Q14 <br /> ; i <br />