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�'A►� <br />BACKWATEF' PREVENTION C►EVICE FIfvAL <br />IN�TALLA�'ION CHECKLIST <br />Inslallation Company Name and Contact Info: _ L,; � rt1 Yf� L i L' � 1"�- L�4I� iS �p;� I N(, __ <br />� <br />Date 6ackv;ater Prevention device (BN�D) ���as installed: �f3 �I �__ Dale this form v;as completed: �������5 <br />Inslallation Property Ovmer Name and Contact Info:-f(v��J-�-� ��'�� S'����^'" ____ <br />Proper,y Address: � � 0�7 � ��`�S% (,s.l��-� W4 � g � � -- - <br />Pre-histallaticn Inspection Checklist: <br />All items must be checkea 'Yes' in order for a RWD fo oe considered for installation <br />Is thera a basement er levefof the house thal is at or near assumed seerer main elevation? Yes ❑ �o <br />Hre there fixfures in the hous� located baiow the upsfream sewer manhole rim elevation? Yes ❑ No <br />Is the side sev:a; currently UNPROTECTED from se�ver backups (does not have a t3VdD Instzlled)? [�Yes ❑ No <br />Site Inspection Checklisi: <br />Afl itcros must b� checked 'Yes' be(ore inspection rs considered complel�� <br />Was side se�ser 7V inspzcted irom building to seti��er main? [v�j"�es j No Condi�icn: <br />Does side sewer have af least 1°�o slnpe irom fhe buildiny lo sevrer main? (� Y/es ❑ No�� /Describ�. _____ <br />Have all building setiver drain r,onnections to the side sewer been identi(ied and localetl? ��J Yes ❑ No <br />Have all properiy storm drainaye connections to lhe side se�ver been idenfifed and located? [� Yes � t�;o <br />Has property been evaluated for drainage deficiencies vaith findings communicated to prcperiy owner? [v�Ye; ❑ No <br />Installation Details: <br />UV1iat lype rind brar.d of BWD v+as installed at this site (Clean Cher,k BV�N, (irinoai pump, etc.): _C �Q�.� c�t _ <br />VJnere was (he tlevicr installed (general description, aflar,h map)'? 1Utr eoc r.�r ��-' h o�s` ______ . <br />1'das Ihere any other sewer or slr,rm drainage vrork completed in wnjunction vdilh G ie BVJD �vork? Is so please describe N� <br />Installation Checklist: <br />Are all downsp:,uls and site drainage disconnected irom upstream o( the BWD? �] Yes [ No Commenis: ._ __ ___ <br />Does E3VJD po�ilioning meels minimum slope requirement of > i%'? ��es ❑ No Com nts: _ <br />Can BWD he pulled out (or inspection and maintenanoe afler loosenir�g Ifwmb screef? � es ❑ No <br />Is E3Wfl loc4ed inlo the proper positinn and thumb screw �ightened? L✓J Yes ❑ No <br />Circle thc BWD cover. ir ,•` ye�seej-heecess hafch (building) <br />,�w�. t <br />4Vas property o�tmer shown lhe loca(ion of lha installed B4VD? �_ Yes ❑ No Comments: __ _ <br />Prc,perly0��vner'sSiynalure:, /_/__..._ :__ Dale: �2-a�5 <br />�----- �� ---- _ <br />Inst:�ller's Signature: �__ �_ S ��__ Date: �� �_ <br />Hevision: 7 1 Mon�ay, September ] 5, 101�i <br />