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i <br /> BACKWATER �REVENTION DEVICE FINAL <br /> ; <br /> INSTALLATION CHECKLIST � <br /> , <br /> ; <br /> Instaliation Company Name and Contact Info: ��o �Jl ' <br /> Dzte Bac�.tivater Prevenlion device(841'D)was instailed: S�' -�S Date this form�vas completed: s-�r� <br /> Installation Properfy Ow�ner Name and Contact Info:�s�lnr cA S..n�a"�" ; <br /> Prop°rlyAddress:�� `z1 V�..-.,. 1 �� O�v� • — i <br /> Pre•Installation Inspection Checklist: � <br /> ,411 items must 6e c�hecked'Yes'in order for a BVJO to be considered for lnstallation f <br /> Is there a basemenl or level of the house that is at or near assumed sev+er main elevation?� Yes ❑No i <br /> Ar2 there fi�ures in the house focated below the upstream s=�ver manhole rim elevation?[�]Yes ❑�'o � <br /> Is the side sewer currenlly UNPROTECTED from seerzr bzckups(does not have a BWD Installed)7[�Yes ❑No ; <br /> Site inspection Checklist: � <br /> A!I items must 6e chocked'Yes'be for�inspection is considered c�mpfete ! <br /> N'as side seu�er N inspected from building to setiver main? �Yes ❑No CondiHon: <br /> Does side setver hava at leasl 996 siopz from the Suilding to s iver main? �Yes ❑No Describe: <br /> Have all building sewer drain connectlons to the side sewer been idenlified and locafed? Yes ❑No � <br /> Have ali prop2rty stom drainage connections to the side sewer been identified and looated [�]Yes ❑ No ! <br /> Has property been evaluated for drainage deficlencies with findings communicated to property ow�ner7 [y]Yes ❑No ; <br /> i <br /> Instaliatlon Details: � ; <br /> What t;�pe and brand of 81��D was installed at lhis si (Clean Check BWV�Grihder pump,elc.): ; <br /> N'here was the devica installed(general description,attach map)? ��o��ti- a ���E�1 � .G+�t (�('�t�ln�� <br /> C� ('�uG,�C —�— <br /> Was there any other sewer or storm drainage H�ork co�np�d in conjunc6on with the BWD�•iork?Is so please describe:_ �. <br /> N ; <br /> Instellalion Checklist: � ,r � <br /> /ve all downspouts and sile tlrainage disconnected from upsiream of ihe BWD? ❑Yes � No Commenls: ����csL ; <br /> Does 81�VD positioning meets minimum sfope requirement of>t%? qJ Yes ❑No Comments: ; <br /> Can BWD be pulled ouf ior inspection and mainienance a8er loosening ihumb scre�v? �Yes ❑No � <br /> Is BWD locked inlo the wpe position and ihumbsc�ew tlghtened7 �Yes ❑ No ' <br /> Circle the BWD crove irrigalion crover(landscape area�l Uaific Icad bearing cover(drivo surface)12ccess hatch(building) ; <br /> Was property ov;ner shovm the localion of ihe fnstalled BWD? i�Yes ❑ No Comments ; <br /> � <br /> Property Oa�ners Signafure: Date: j <br /> I <br /> Installers 5ignature: _ Date: �- ��`c� - I S I <br /> Revisfon:2 �/1 friday,September 12,2014 � <br />