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( <br /> ; <br /> E�ACKWATER PREVENTION D�VICE FINAL � <br /> lNSTALLATION CHECKLIST � <br /> I <br /> i <br /> Installatlon Company Name and Contact Info: ��n l�r� PI� ��n���� j — I <br /> Date Back�vater PrevenGon device(BW�;:�as instalied: S"��U- 1� Date this fortn was completed: �—��f5� i <br /> i <br /> Installation Proper�y Owner Name and Conlact Info: �-�v C-r��c�� ^�� — � <br /> ProperiyAddress: 1`Ilq I,o�nn4r �rQ IA:�� — - i <br /> Pre-Installation inspection Checklist; j <br /> All rtems must 6e checked'Yes'in order fora BVJD to be considered for InsfallaGon � <br /> Is there a basement or levei of the house that is al or near assumed sewer main elevation?�Yes ❑No � <br /> Are tliere fixfures in the house loraled below the upstream sewer manhole rim elevalion?[�Yes ❑No � <br /> Is the side sewer currenUy U�PROTECTED fmm sewer backups(does not have a BW�installed)1�Yes ❑No � <br /> 5ite Inspeotion Checklist: � <br /> Alf items must 6e checked'Yes'befor�inspecfion is considered complete i <br /> � <br /> I��as side sewer N inspected from building to sewer mainl �]Yes ❑ No Condition: : <br /> i <br /> Does side sewer have at least 1%siope from the building to sewer mainl Yes ❑No Describe: � <br /> Have all building se�ver drain conneciions to the side se�;er been iden6fied and locat:d? �Yes ❑No I <br /> Have all propetty storm drainage wnnections to Jhe sfde se���er been identified and located? [[]Yes ❑No ; <br /> Has property been evaluated for drainage deficiencies vrith findings ammunicated lo property o�s�ner7 �Yes ❑ No j <br /> . � <br /> Installation Details: — �� ! <br /> INhat type and brand ot BIND was inslalled al this sit (Clean Check B1h�,Grinder pump,etc.): I <br /> lNhere was lhe device instailed(general description,a a�frma�}? �n,�' �a�c9 l� ���� �c"�-i`�' ; <br /> � <br /> Was there any other setver or slotm drainage work compleled in conjuncUon wilh the BN�D work?Is so please descnbe:_ i <br /> - � i <br /> Installation Checklist; ; <br /> Are all do�mspouls and site drainage disconnected from upsfream of the BWD? [�Yes ❑No Comments: I <br /> Does BWD positioning meefs minimum slope raquirementoi>1%1 �Yes ❑No Comments: � <br /> i <br /> Can B1ND bz pulled out for inspection and mainlenance after loosening lhumb scretiv? [�Yes ❑�o � <br /> Is BWD locked into the �erposidrnrand ihuml�screw Ughlened7 (Z]Yes ❑No � <br /> Circle ihe BWD co er. imgafion cover(landsca e area)I iraffic load bearing cover(drive suriace)!aceess hatch(building) ; <br /> Was property owna bown-the�location of the installed BWD� ,�Yes ❑ No Comments: � <br /> Property Owner's Signature: Date: `: <br /> Inslallers Signature: Date: �'� —�S j <br /> � <br /> Revision: 2 � 1 friday,Septemher 12,2014 <br />