HomeMy Public PortalAboutBACKFLOW DEVICE DESIGN DATA AND PLUMBING PLAN WITH APPROVALTOWN OF WATERTOWN
DEPARTMENT OF PUBLIC WORKS (P) 617-972-6420
124 ORCHARD STREET (F) 617-972-6402
WATERTOWN MA 02472
Gerald S. Mee Jr.
Superintendent
BACKFLOW DEVICE DESIGN DATA AND PLUMBING PLAN
MUST BE SUBMITTED AND APPROVED PRIOR TO INSTALLATION
A. PROPERTY OWNER INFORMATION
Owner Name
Street Address
City State Zip Code
B. FACILITY INFORMATION Is this Facility New or Existing (circle one)
Facility Name
Street / PO Box
City State Zip Code
Contact Person Telephone Number
Describe the type of business or activities carried out at this facility:
K OACKFLOWIBACKFLOW DEVICE DESIGN DATA AND PLUMBING PLAN WITH APPROVAL.doc
C. DEVICE DATA
Exact Device Location
Make Model Size Hot or Cold Water Unit
Type of Gate Valve (Must be UL or FM approved for fire systems)
RPBP DCVA PVB (circle one) Bypass Arrangement Yes ❑ No 0
From what type of contamination is the water supply protected?
How many other RPBP or DCVA are located in this building?
D. DEVICE MAINTENANCE and TESTING SCHEDULES
Describe the maintenance and testing schedule of the above device (s) please refer to 310 CMR 22.22
E. CROSS CONNECTION PLAN SUBMITTAL REQUIREMENTS
A. PLUMBING PLAN
1. Completed title block (name of facility, address, date, preparer, etc.)
2. Schematic or blueprint of plumbing system (at least 8 % x 11)
Using accepted symbols and nomenclature, detailing
• Location of upstream and downstream shutoff valves
• Make, model, size, and alignment of device
• Location of potable water lines
System, source, or equipment fed downstream of device, complete with
information on the secondary system (operating pressure, chemical treatment, etc)
• All RPBP, DCVA, & PVB's must be installed in a horizontal configuration.
RPBP's and PVB's must be installed between 36" and 48" above finished
floor. DCVA's must be installed between 30" and 55" above finished floor.
This Design Data Sheet is only for the approval of a backflow installation. All other permits must be
acquired from the respective city/town offices.
Submitted By:
Address:
Date:
APPLICATION APPROVED BY:
Phone:
For City /Town Use --- Do no write in this section
DATE:
K.1BACKFLOWIBACKFLOW DEVICE DESIGN DATA AND PLUMBING PLAN WITH APPROVAL.doc