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BACKWATER PREVENTION DEVICE FINAL <br /> �, INSTALLATION CHECKLIST <br /> Installsiion Company home and Confact Info:�5�tw�e—��y ��`�"t�" �G'�a�65����J,� <br /> Date B�ckwater Prevention device(BVJD)���as installed:�s� � Date Ihis form was completed: -/S� <br /> Installation Prdperty Ovine�Nar�e and Contact Infb:�2�-� ��^��-� y�a��-3g/� <br /> ProperlyAtldress: �31b oad�r,��r�_0_� <br /> Pre-Installation Inspection Checklist: <br /> All items must 6e checked'Yes'rn order lor a BN�D to be considered for installafion <br /> Is there a hasement or levef of lhe house tha(is at or near assumed se�;er main elevation? Yes ❑No <br /> Are t'nere lixtures in ihe house loca�ed below the upstream sev�er manhcle rim elevalion7 Yes ❑�./No <br /> Is the side sewer currently UNFROTECTEd from sewer backups(does not have a BWD install�U)?�y Yes ❑ IJa <br /> 5ite Inspecti4n Ghecklist: <br /> A!1 i(ems must be checked'Yes'befae inspection is considered,�ompJete � <br /> Was side setver TV inspectetl trom;;diltling to sewer main? �Yes ❑ N�oy� Condition: <br /> Does side sewer have al least 1%slope irbm ttie building t6 sewer main? LVJ Yes ❑No Deseribe: <br /> Have ali ouild� ,g sewer drain conneclions to lhe side sewer Been idenlified and located? � Yes ❑ No <br /> Have all praperty stants drainage connections to the side se�.ver been identified and located7 �Yes ❑�,�o <br /> Has properly been evaluated for drainage deficiencies vailh findings communicated to property owner? I�Yes ❑No <br /> Installation Details: (�� � <br /> What lype and brand of BWD was inslalled al lhis site,/C�lea�n�Ch k BINVr IG�rinaer p��np etc.): I� � <br /> Where vaas the device ins4alled(general description, alla\ cTi map)? 5ov.`t'vl CIG� � �' � � <br /> Was Uiore any other sewer or siorm drainage�vork completed in conjunction wiih the BWD work?Is so p!ease describe:�('j <br /> � Installation Checklist: <br /> Are all downspouls and site drainage disconnecled from upstream of th BWD? Yes ❑No Comments: <br /> Does BN�P positionin�meets minimum slope requirement of>t%? Yes �]No Commenls: <br /> Can BWD be pulled oul tor inspeclion and maintenan�e atter loosening umb screw? �'es ❑No <br /> Is BWD locked into the proper position and thum�-ssr w tightened? �Yes ❑ No <br /> Circle lhe BWD wver: irrigatlon cover(landscape are Iraffic load�earing cover(drive surtace)/access hatch(buildingJ <br /> Was properiy owner sho��Jn ihe losation of the installed BWD1 �Yes ❑ No Commenis: <br /> Propeity Owner's Signatur ; ' `� 1 / Date: S" (� " aD�� <br /> InStallAr'S Signalure: Date: �i —� ��l7�_ <br /> Revision: 2 1 Monday,September 15,2014 <br />