Laserfiche WebLink
BACKWATER PREVENTION DEVICE FINAL <br /> ,� INSTALLATION CHECKLIST <br /> .r• ' �c'„��, <br /> � ,�.. . r :� : �- �; , , f:;=� ��.� ,�.�_ <br /> Installation Company Name and Contacl Inio:, � i� ' !'1 z•'r r i- � �r � d".l �--�- �--=� '.' "��� <br /> Date Backviater Prevention devicc (BUJD)v:as instalied: � �� Da?e this form was comp'eted: la <br /> Inslallation Property Owner Name and Contact Info:y��'pC',:5�����5'�' �°Z� '�5 7 — �r�'/� <br /> PropertyAddress: IC�I R rE'� 'Z��____.__�t�'�d.�'�` a �`��� _ <br /> , <br /> Pre•Installation Inspection Checklist: <br /> „II items must be checked 'Ves'in order for a BWD to be considered for installation <br /> Is there a basement or I?vel of the house that is at or near assumed sewer main elevation? (�%Yes ❑ No <br /> A•e there fi�Aures in Ihe house located belo�v the upstream se�ver manhote rim elevaGon?(�j Yes ❑ No <br /> Is the side sev:er currenliy UNPROTECTED�rom sewer backups(dees not have a BWD ins(ailed)? �Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must 6e checked 'Yes'before inspection is considered comp!efe �- �_�, � <br /> �Vas side sewer TV inspected irom building to sewer main? �(j Yes ❑No Condition:_(x�_� <br /> Does side see+er have at least 195 slope from lhe building to sewer main? �Yes ❑ No Descnhe:_ <br /> Have all building sewer drain connections to ihe side se�ver been identifed and localed? �Yes ❑No <br /> Have all property storm drainage conneclions to the side sev+er been idenGfied and located? ,�Yes ❑ No <br /> Has propeAy heen evatuated for tlrainage deficiencies v+ith findings communicated to property ovmer? �Yes ❑ No <br /> Installation Details: � <br /> What rype and brand oi BWD�:�as inslalled at this site(Clean Check BWV, Grnder pump,etc.): Gs � � <br /> !Nhere was the device installed(general descriplion, attach map)7 ��p�qS�'l���iS_�.(,��� <br /> �Nas there any other ser�er or slorm drainage work compleled in conjunction�vith Ihe BWD vrork?Is so please describe:_ <br /> -- �ctl'l_0 <br /> Inctallation Checklist: <br /> Are all downspouts and site drainage disconnecled irom upsiream of the BWD? [�Yes ❑No Comments: <br /> Daes B'ND positionir,g meels minimum slope requiremenl of>1°5? (�Yes ❑ No Commenis:__ _ <br /> Can BWD be pulled out for inspedion and maintenance after loosening thumb scre�v? �Yes ❑No <br /> Is BVJD locked into the proper position and thumb screw tightened? �f Yes ❑ No <br /> CirGe the BWD cove irrigalion cover landscape area)1lraffic loatl bearing cover(drive suriace)i access hatch(building) <br /> VJas property owner shovdn ihe location ot lt�e installed BIND? �'Yes ❑ No Commenis: <br /> / � �/ <br /> Property Owner's Signature: ` i� 7�� �-( n / Date: / � /'iy /� _ <br /> Installer's Signature:_ � Date: o? C� /lf _ <br /> Revision: 2 1 Friday,September 12, 2013 <br />