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i <br /> BACKWATER PREVEI�TIOfi! DEVICE FIiVAL I <br /> E,• INSTALL/�TION CHECKLISl' ' <br /> � <br /> I'�'lE'f i Gc:rn s:K'f� � c� ^r `��de : c'atX�', L LG � <br /> Installation Company Nameand Contact Info�.S� ��i 'C'� J�,)174�-�115//���.ii'N� (�:K;):�/i0 -.�/I��C� <br /> Cale Bac.kwaler Prevention device(8WD)v��as instailetl:� '�� - )5 Qate ihis i m was completed:�1J_ � <br /> Installation Properiy Owner Name and Contacl Info: Yl� _{�� �) ------ � <br /> I ` �; U ' <br /> PropertyAddress ��'J��J �i{ ��'1__K��:IN - �iU�1��I� ,.�1Y1 y[.ZiU/ i <br /> � <br /> Pre-Installation Inspection Checklist: <br /> �N ilems must be checked'Yes'in ader Inr a RWD fo be r.onsidered for instaNafion � <br /> Is ihere a basement or Ievel o(ihe house that is at or near assumetl seiver main elevation?[�s ❑ No � <br /> Are ihere iktures in fhe house lor.aled below the upsVeam sewer manhole rim ele��aGon?[�es ❑ No � <br /> Is the side sewer curtenfly UNPROTFCTED f�om sev�er backups(does not have a BVUD insialled)? es ❑ No ; <br /> Site Inspection Checklist: � <br /> All ifems must be checked'Ves'belore inspecfion is considered complete �,.�1 i <br /> Was side sewer T�/inspected irom huiltling to seiver main? �Nes ❑ No Condition� "�](XX➢ _ __ ___ i <br /> r�� <br /> Does side sev�er have at Icast 1%slope irom the building �o sewer main? (�Yes ❑No Describe: ' <br /> Have all building sewer drain connections to the side sev:er been identifed and located? �'��'`"?.,��es ❑No � <br /> Have all properly storm drainage conneclions ro the side sewer been identifed and located? �l'es ❑ No <br /> I <br /> Has property been evaluated for drainage deficiencies with findings communicaled lo property owner? �i'es ❑ No <br /> Installation Details: ' <br /> What type and brantl o(BWD was installed at ihis site(Clean Check BWV, Gnnder pump, etc.) - ' <br /> Where �vas Ihe device installed (general descnpiiun, altach map)? �, � ���IP�:S_I�L��J _ � <br /> r�� � - <br /> --- -- - � <br /> N�as ihere any o�her sewer or storm drainage work compleletl in conJunction with the BWD woik? Is so please descnbe. _ � <br /> --- -- -- --- — -- —=-l�1cn1.P _ i <br /> Installatlon ChecklisL <br /> Are all downspouls and site drainage disr.ronnected from upstream o(the BUJD? (�Ycs [� No Comments__. __ _ <br /> Does BWD posilioning meets minimum slope requirement o(>i%'T [�1(Yes ❑ No Commenls:.__ __ __ � <br /> Can BWD be pulied out for inspectlon antl maintenance after loosening Ihumb screw? �jYes �_ � No j <br /> Is RWD locked into lhe properposition and thwnb screw lightenetl? [�Yes ❑ No i <br /> Circfe the BN'D cover. riyalion covei ndscape area)I Iraftic loatl bearing cover(drive suriace)I access hatch(huildin�) i <br /> �_.� <br /> UVas p�operty ovmer shown ihe localion oi the installed BIND? �Yes ❑ No Cortimenls:___ <br /> � � , <br /> Property Owner's Signature: Date: � � � � <br /> Installer's Signature ___ _ _ Date: � a ��_� ', <br /> Revision: 7 � 1 priday,Septembcr 12, 7014 ' <br /> � <br />