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� <br /> � <br /> � <br /> � <br /> � BACK'U1�ATER PREVENTION DEVICE FINAL <br /> E� lNSTALLATION CHECKLiST <br /> �.� , <br /> lnstallation Cornpany Nan�e anci Co��i�ici In(c�`fii�.kr�tce.f�`:� ���Si�E��,��((�rt� �.�'��(;`t c�;"'� �(������ � -- ���3 �� -' <br /> _ __ _ _ <br /> � — _ <br /> - <br /> Date Back�vafer Prevention devicc {BWU) w�as insi<311c�c1.._��l� i S � _ f)r�ic: Iliit; (c��n� v�;i:; c;c��i�F�l��lc��! � �`� � _ , <br /> Installation Property Owner Name and Gor�lacl I�i(o����`� �i��� �� ` <br /> _ _ � ----_ <br /> Properfy Address; I���r ���`�%� <br /> --- --.._-- -- ------ _._ <br /> _ _ ._ ..____ . _ . . .... <br /> . . .-- ---- <br /> � <br /> Pre-Insfaflatian Inspection Checklist: <br /> All iterns must be checked`Yes'it� order fa�a BWD lo be r,oi�srdcre�l fiu�i��sfallali��ri <br /> � <br /> Is fhere a basement or levei of the house ihaf is al or near�3ssumed sewer m�jin elev��tion'? � �c:, � j No f <br /> � <br /> Are the�e fixtures in the house located below the upstream sc�wer manhale rim elev��tic�n'? �`� Yes � ) Nc� ` <br /> Is fhe side sewer currently UNPROTECTED from sewer backups (cioes nc�i Iz�vc�a QWl� i�rs1�311c:d)? � „Yes � _]No :'. <br /> Sife Inspection Checklist: <br /> Al!rfems mus�be checked'Yes'befor�inspecfior�is coi�sidc�ed con�pletc <br /> Was side sewer N inspected from building to sewer main? [�es �_� No Cc��7diiion: <br /> --.._____ ____�_ . � <br /> poes side sewer have at least 1%slope from the builciinc� t�sewer main? [��"Yes J ) No Uese;ni�c� __________.�._ <br /> Have all building sewer drain conneetions to the side sewer t�een identffied��nc1 Ic�c.�:�tc.cl? �r'�Yes ( � Nu <br /> , <br /> Have ali property storm drainage connections to the side snwer been identified artd lac��fed? � !�'Yf�s � ] No <br /> Nas prop�rty been evaluated for drai��age deficiencies wiff7 findings co�nrn�uiic��i�:�� lo E�r��G>eiiy r�wn��r'? ��es [��� No � <br /> Insta(lation Details: <br /> What type and brand of BWD was instaHed at ihis site(Cle��n Cf�eck BWV, Grinder��un�p, cic.): �'�l-��� � �-��� � <br /> _� __ -- <br /> Where was the device installed eneral descri fion attach n�a� ? u��r_����r'���4�_� ����_��e''� ��� <br /> {9 P , f) �._. ( -�-- <br /> Was there any other setiver or ston�drainage work compleied in conjunction wifh thc: I3WD wc�rk? l�sc���lease describe; _ { <br /> lnstaflation Checklis#: <br /> Are alf downspouts and site drainage�isc�nnected frorr�u�stream of tr�e BUUD? ��.�°"Yes � � No Corr�rnc�ii(s- � <br /> _ - _.____ � <br /> Does aWD positianing meets minim��m slope requirementof>1%? (_`�c's ( _� Nc� (:�m�n�c�nls; _ _..__----------___ _--- � <br /> Gan BWD be pul(F�c1 out for inspccli�n ���d m��inl��nr3ncc��Ilf;r I����s�rzinq (li�in�l�s�;r�r�w'� 1 ��Yc�s � � N�i <br /> Is BWD I��r,ked inta tlic proper positi�n and ihumh Sc�E:w tighf�ned`� �. �es� � _ ) No •� <br /> �__ <br /> , , <br /> Circle th��� BWD c�ver. irrigation cov�r{I�ndSc�F�� arr:��)%(r�fFc I��d be�ring cover(��rive s��r(<ic��)/��r:r,cr�s IT��fel�i (l�uil�iirr��} � <br /> �--� �_. � <br /> Was ��ro����r(y owner shown the location of[he in5t��fled BW[�7 ��Yes � ' Nc� (:�3innic:nls: � <br /> . � <br /> ; <br /> Prop�;�iy Owncr'�� Sir�nafure� __._.__�._.-----__ _. (�),i1i': - � <br /> , � : � ���. _ _ _. <br /> , ---- <br /> 1:�5i:�li�:�i �, ;���i �„ilur� - � �' _.' '` . _.�' .� _._�---�_�— __ _. .__ � , �� ���1 � <br /> 1 L-. I);i�:. ; <br /> E <br /> F�E=��I'Jii(1 . � �,'���)I}I�J�', �il��)ii'(Il�li'I �� , .������� <br />