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� I <br /> i , <br /> � �ACKWATER PREVENTIOIV �EVICE FINAL j <br /> d INSTALLATION CHECKLIST i <br /> � <br /> �r►c«n �;�+�-�� �r s�e < c�z�-, L LG ; <br /> Installation Company Name and Contact Infc;T�Ci � �i?";�` ^����� '��' �'`���'�''�� �j�� . <br /> Date Daclnvaler Preve���nn device(BWD)v;as ins�.alled: Date this form was completed: � � � <br /> Installation Properly Owner Name and Contact Info:_�,a/jJL�'�.(` ,�1°!'1 (, �'�/( ' ' O <br /> Property Address: ' � , ' i � a b`�O� ° <br /> �� i <br /> Pre•Installatiun Inspection Checklist: ' <br /> Afl ifems must be checked'Ves'in order for a BIND to be considered for installation <br /> !s there a basement er level of the house that is at or near assumed sewer main elevation? [�Yes ❑No ; <br /> Are Ihere fixlures in Ihe house lor.ated below Ihe upslream sewer manhote rim elevalion7 �Yes ❑No ' <br /> Is the side se�ver currenUy UNPROTECTED(rom sev�er backups �does not have a BWD insfalled)? [�Yes ❑No <br /> Site Inspection ChecklisL• � <br /> All items must be checked'Yes'before inspection is considered complefe ���( ' <br /> VJas side se�var TV inspected irom building to sewer main? [�Yes ❑No Condition: C..��' � <br /> Does sitle sewer have at least 190 slope irom the building to sewer main? [�Yes ❑ No Describe: ' <br /> T " <br /> Have all building sewer d2in connections lo the side se�ver been identi(ied and located? �es ❑ No i <br /> Have aIi property storm drainage wnnections to lhe side sewer been identified and locatetl? �es ❑ No � <br /> i <br /> Has properiy been evalualed for drainaoe deficiencies wilh 6ndings communicaled to properly owner? �Yes ❑No � <br /> i <br /> installation Details: ' <br /> What iype and brand of 81ND was installetl at this sile(Clean Check DWV, Grinder pump,etc.): �r ! <br /> Where was lhe device inslalted(general descriplion,attaoh map)7 _ � 't� + i(� i <br /> � <br /> Was lhere any other seever oi storm drainage���ork compleled in�njufn.'cG�o,n�vilh the BWD work7 Is so please describe:_ ; <br /> � � <br /> r ; <br /> Instailation Checklist: � <br /> Are all downspouls and site drainage disconnected irom upslream of the DWD? �Yes ❑No Commenls: i <br /> Does BWD positioning mcels minimum slope requirement oi>i°;o7 _�j�Yes ❑ No Comments: __ <br /> Can BWO be pulled out(or inspectinn and mainlenance after loosenir g thumb screw? �Yes ❑ No <br /> Is OWD locked into the ro er position and ihumb screw tightened? �Yes ❑No , <br /> Circle the BWD cov irrigalinn cover ndscape area)!tranc load bearing cover(drive surface)f aecess halch(building) <br /> Was property owner shown Ihe location o(ihe inslalled BWD? [�'Yes ❑ No Comments: <br /> Property Otivner's Signature: ` - -�-• Date: � 5�— ! S / ' <br /> Inslaller s Signature: Date:�;� ' 7 'G J , <br /> � <br /> Revision:2 1 friday,Sep[ember 12,2014 � <br /> i <br /> � <br />