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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company N, ie and Contact info: ��-a PCuv�n�iNU_ u.L <br />Date Baclnvater Preven6on device (BNlD) vras installed: �'- �4- '� Date this fortn was completed� S- Z9 —/i <br />Inslallation Properiy 0:vner Name and Cont�ct Info: �N�C/C � d�pOL/��} 7p-7_ 33'7 -?S¢ro <br />Property i�ddress 3 2U ( W c.r3'm2� rrr L�1/Cnc�-7'T' �l} • �I Pi 2 t� 1 <br />Pre-Installation Inspection Checklist: <br />Afl items must be checked 'Yes' in orde! fw a BWD fo be considered lor instailaGon <br />Is lhere a basement or level o; the house �hat is at or near assumed sewer main elevation? �j Yes ❑ No <br />Are there fixfures in the house located below thz upstream sewer rr:anhole rim el�vafion? �j Yes ❑ No <br />Is ihe side setiver currenlly UNPROTECTED from sewer backups (does not have a 9WD installed): ,,, es ❑ No <br />Site Inspection Checklist: <br />All items must be checl;ed'Yes' betore inspecfion is considered complele <br />ti'as side sewer N inspected from building to sewer main? �Yes ❑ No Condition: <br />Does side sev�er have at lezst i°6 siope irom Lhe 6uilding lo sewer main? �J Yes ❑ No Describe: _ <br />Have all building sewer drain conr,ections to the side sewer beon idenli5ed and located? � Yes ❑ No <br />Have all property slorm drainage connections to the side sewer been identified and located? � Yes ❑ No <br />Has property been evaluated for draina�e deficiencies wiih fi�dings communiu�ted to nroperty ovme�7 �Yes ❑ No <br />Installation Details: <br />What tyoe and brand o( BWD was instailed at this sit lean C'ieck BN , Gnnder pump, etc.): 2- � N� � Wl�� <br />VUhare tvas ihe devi�e installned (aen'/eral descnption, attar,h map)1 _�NS%7� 1�� / N � NCH <br />��1NN II /./� ? ��1� <br />fl //`� <br />V�'as there any other sewer or storm tlrainage work ��npleled in conjdncGon ���ith ihe BWD work7 Is so please describe: <br />Instailation Checklist: <br />Are all dovmspouts and site drainage disconnecled irom upsUeam ot the BVJD? � Yes ❑ No Commenls <br />Does BWD posi6oning meets minimum slope requirement of >1%? es ❑ o Comments: <br />Can BWD be pulled out (or inspe:tion and maintenan�e after looseni ihumb screw? � Yes ❑ No <br />Is BWD locked inro ihe proper posiUon and thumb screrv tightenecl? �(J Yes [_j No <br />Cirde Ihe BWD cover: irtiga6on cover (landscape area) I tra(fic load bearing cover (drive surface)/ access halch (building) <br />VJas propery ovme� shown the location o( the inslalled BWD? � Yes ❑ No Comm�nts: <br />/ZN.v�nL COrNCr �c�av�f d' F6�,• <br />Frooerty Owner's Signature: Date: �^ 25� '�� <br />Inst�ller's Signature`L ,> Dale: S 2 t-' /�' <br />Revision: 2 1 Tuesday, September 16, 2014 <br />