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BACKWATER PREVENTION DEVICE FINAL <br /> E,• INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info:�{��//i !�/t�.�/�i va ��7� �) 35s7 �s�7 <br /> Date Back�vater Prevention device(BWD)was installed: i��,.��I�� Date lhis form was completed: � i� <br /> Inslallation Property Ovmer Name and Contact Info: �i a��• ��-- c• ev- e��' <br /> PropertyAddress: 3�%��!'�iJ ✓.G�� S' Y-'ve:�rt� •�_ 'l�%ti%J <br /> Pre-Installation Inspeclion Checklist: <br /> All ifems must be checked'Yes'in orde�,'ora BbYD�o be considered for installafion <br /> Is there a basemenl or level oi the house that is at or near assumed sewer main elevalion? (�Yes ❑ �o <br /> Are tnere fixtures in the hcuse Ir ated below the upstream sewer manhole rim elevation?�Yes ❑No <br /> �s lhe side sewer currentiy UNPROTE�TED(rom sewer backups (does not have a BIND installed)?(�Yes ❑ No <br /> _ � <br /> Site Inspection Checklist: <br /> AIf items must 6e ef iecked'Yes'be(ore;nspecfion is considered complele <br /> 14'a,side setit�er N inspecled from buildin�to se�,ver main7 (�Yes ❑No Condition: <br /> Does side sevrer have at least 1`/o slope from the building to se�ver main? [�Yes ❑ No Describe: <br /> liave all building sewer drain ccnnections to the side see�er been idenlified and located? �Yes ❑Nu <br /> fiave all property storm drainage connections to lhe side sev+er been idenlifed and localed? [�Yes ❑�o <br /> Has property been evalualed for drainage deficiencies wilh findings communicated to property o��mer? j�Yes ❑ No <br /> .� <br /> Installation Details: <br /> VNhat type and brand of BIND was installed at this site(Clean Check BWV,Grinder pump,etc.): /.1<a� Ghc;G/� <br /> Where w.as the device installed(general description, attach map)? �?��,L• �7,-��c� u�D �r«i <br /> /�/!e'y 1:%cG,n.s we5f _ <br /> Was there any other sewer or storm drainage work completed in conjunction�vith Ihe BWD work?Is so piease describe:_ <br /> NC/ <br /> Installation Checklist: <br /> Are all do�vnspouls and sile drainage disconnected Irom upsiream of Ihe BWD? '�Yes ❑fvo Commenls: <br /> Does BWD positianing meels minimum slope requiremenl oi>1%? �Yes ❑No Comments: <br /> Can BWD 6e pulled out for inspection and mainlenance atter loosening thumb screw? (�j Yes ❑No <br /> Is B�VD locked into lhe proper posilion and lhumb screw lighlened? [�Yes ❑ No <br /> Circle Ihe BWD cover.�rri�at` cover(landscape area j ira(fic load bearing cover(drive suriace}/access hatch(bui!ding) <br /> Was property owner sho�vn Ihe location o I e installed BWD? �Yes ❑No Commenls: <br /> �.. <br /> Property Owner s SignaWre: Date:_J' � ?/��/ <br /> Installer'sSignaWre� _--- Date: �r � .�/ �� <br /> Revision:2 1 Friday,September 12,2014 <br />