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� <br />,�► �ifl <br />BACICWATER PREV�tNTION DEVICE FINAL <br />iNSTA�LATION CHECKLIST <br />Inslalla6on Company Name and Contact Info: <br />pate Backwa�er Preven6on device (BWD) was <br />this form was completed: nCT=2-2� S <br />Installation Property Owner Name and Cantact Info: ! l� ��2 %l��{--� � ��- <br />Property Address: 3 � Z o l.�-� �5`t- YY'�"xJ i r�.e. U 1�.�.� ��• �Fi n�T <br />Pralnstallation Inspection CAecklist <br />All rfems must be chedred 'Yes' in order for a BWD to be consrdered (or instalfafion <br />Is there a basement or level ot fhe house that is at or near assumed sewer main eleva6on7 [t�Y�s ❑ No <br />Are there fixtures in the house tocated below Ihe upstream sewer manhole rim elevabon? [��'�es ❑ No <br />Is the side sewer currenlly UNPROTECTED fram sewer backups (dces not have a BWD installed)7 [�Y�s ❑ No <br />SRe Inspection Checklist: <br />All items must be checked 'Yes' ufore inspecfion is oonsitie2d comptefe <br />Was side sewer N inspected irom huilding to sewer main' D�s ❑ No Condition: T_ �G � R--� <br />Does side sewer have at least 1°h slope from the buiiding lo sewer main? D�s ❑ No Describe: <br />Have all buiiding sewer drain amnEclions to the side sewer been iden '6fied and located? �❑ No <br />Have ali pro;terty storm drainage connections to the side sewer been iden6fied and located? �❑ No <br />Has property been evaluated for drainage deficlencies with findings communicated lo property owne� 1 ��es ❑ No <br />Installation Deteils: /� <br />What type and brand of BWD was installed at this site (Clean Check BYJV, Grinder pump, etc.): ( C�-C'-��-C�C. <br />Where was the device installed (general descrip6on, attach map)? P t1"��� i�> 1`�'ti b�e.� � <br />Was there any qlhe sew r or storm drainage work mpleted in con unction with the BWD work? Is so please describe: _ <br />v�-r�r�d n�-I�U-�w�2�•� - - <br />Insbllation Checklist: <br />Are ali downspouts and site drainage disconneded trnm upstream o( the BWD7 �� ❑ No Commenfs: <br />Dces BWD positioning meets minimum slope mquirement of >1%? �� No Comments: <br />Can BWD be pulled oul for inspection and maintenance after loosening tnumb screv/t es ❑ No <br />Is BWD locked into tlre proper posibon and thumb saew fightened7 �'es � No <br />Circle the BWD wver. imgation cover (landscape area; c load bea-- rina drive s�'aocess hatch (building) <br />Was property owner shown the location of the instailed BWD? es ❑ No Commenis; <br />Installer's <br />Revision: 2 <br />Date: OCT— /� / S <br />Date� �— Z—� <br />Friday, September 72, 2014 <br />