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i <br /> � <br /> i <br /> , <br /> BACKWATER PREVENTION DEVICE FINAL <br /> �. lNSTALLATION CHECKLIST � <br /> i <br /> ; <br /> i <br /> Instalialion Company Name and Contact Inio: jIo l��v� �n �-7Gk� ; <br /> i <br /> Date Back�vater Prevention device(5U1�D)�vas inslalled: ZO/S Date this form was completed:�S� � <br /> Installalion Prcperty Owner iVame and Contact Inio: � <br /> PropertyAddress: �2�2 ��uplQ S}�cci Fve��W� 1�ZD� I <br /> Pre•installation Inspection Che�klisl: I <br /> AU items must be cheeked'Yes'in order for a BVJD fo be considered for instailation � <br /> Is there a basement or level of the house that is at or near assumed se�ver main eievation?�Yes ❑No <br /> Are there fixtures in lhe house located below the upslream sewer manhole rim elevation? [�]..Yes ❑ No <br /> Is Ihe side se���er currently UNPROTECTED from sevrer backups (do=s not have a BWD installed)?�Yes ❑ No <br /> Site Inspection Checklist: � <br /> All items musf be checked'Yes'before inspection is considered complefe i <br /> �p�( ,a ;,u c i- <br /> 1n'as side sewer N inspected from building to sev:er main? �Yes ❑ No Condition St�y�� �, � �4 ��i� i <br /> � <br /> Does side sev:er have al leasl 1%slope from ihe building to sev�er main? �]Yes ❑ No Descrihe: • <br /> Have all building setiver drain connections to ihe side sew2r been identifed and located? �Yes ❑ No i <br /> Have all property storm drainage connections to the side sev�er been identified and located? �j Yes ❑No � <br /> Has property been evaluated tor drainage deficiencies�vith findings communicaled to property ovrner? �]Yes ❑ No � <br /> Installation Detaiis: ' <br /> 1��hal type and brand of BWD e�as installed at ihis site(Clean Check BWV, Grinder pump,etc.):C�g'^ ��3��� � <br /> 1�'+here ways�lhe dgvice installed (general descripUon, atlach map)? ' <br /> C��)vc1-rQ �Ltc� � <br /> ---'r � <br /> 1�'as there any olhEr sewer or storm drainage work completed in conjunction�vilh Ihe BI��D work? Is so ptc;ase describe: __ <br /> NOj�' --— --- <br /> t <br /> Installation Checklist: ! <br /> Are all do�vnspouts and site��ainage disconnecfed irom upstream of lhe E3WD? �Yes ❑ No Comments: i <br /> Does BWD positioning meets miiimum slope requirement of>1%? �Yes ❑ No Comments: s <br /> Can 81ND be pulled oul lor inspec,�on and maintenance afler looseniny Ihuinb sc�ew? �Yes ❑ IJo � <br /> Is BWD lo�ked into ihe proper posili,m and Ihumb screw tighlened? �Yes ❑ No �� <br /> CirdP lhe BUVD cover; irrigation covei (landscape area)f Iraflic load bearing rover(drive suriace)1 access hatch(building) j <br /> 1Nas properly owner shown the locatior oi tha installed BI�VD? �Yes ❑ No Commenls: � <br /> Properfy Owners 5ignalure: �� _��"' _ Date: L - 5 '• °1 6 � S � <br /> �r , � <br /> Installer's Signatuie: ��:�% Dale: d�s��a� S I <br /> . � %� <br /> Revision: 2 •'� -�� i Friday, September 12,201A <br />