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�� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: �/�o//� /�/rerd��s' �/ZS� 3fs9 /S� 7 <br />Date Baclnvater Prevention device (BVJD) was installed:��� Date lhis form was completed: 1�7 /3— <br />Installation Proper�y0wnerName and Contacl Info: Ne% .Gn/Gt��S� �Z�6� SZ2 /G3 7 <br />Property Address: f �� G/=� nD <br />Pre•Installation Inspection Checklist: <br />All items must 6e checked 'Yes' in order for a BWD fo 6e considered for installation <br />is there a basement or level oi the house that is at or near assumed sewer main elevaGon? (� Yes ❑ No <br />Are there ixtures in the house located belov� the upstream sewer manhole rim elevalion? � Yes ❑ No <br />Is the side sewer wrrenlly UNPROTECTED lrom sewer backups (does not have a BWD installed�'T �Yes �] No <br />Site Inspection Checklist: <br />AII ifems must 6e checked'� es' before inspeclion is considered complefe <br />Was side sewer N inspected from building to sewer main? �1'es ❑ No Condition <br />Does side se:ver have at leasl 1% slope Irom Ihe buiiding lo sewcr main? �'•Yes ❑ No Destribe: <br />Have all building se�ver drain connections lo Ihe side sewer heen idenlified and localed? (�j Yes ❑ No <br />Have all properly storm drainage connections to the side se�ver been idenGfied and located? [�Yes ❑ No <br />Has property been evaivated for drainage deficiencies with findings communicated tu propeRy owner� � Yes ❑ No <br />Installation Details: <br />Whal type and brand of BWD was ins!alled at this site (Clean Check BWV, Grinder pump, etc.): s+an ��-o �/jS l�wD <br />Where �vas the device installed (general description, attach map)? +�� S�. Sd�+zn> i n �Zaa n o i3a,Y <br />�u '/ 7� G G/P��G � <br />�:�as lhere any other sev�er or storm drainage viork completed in conjunction with the BWD �vo�k? Is so piease describe: _ <br />Installalion Checktisl: <br />Are all do�vnspouls and sile Jrainagc disconnecled from upstream ot the BWD? �Ycs ❑ No Commenls __ <br />Does BWD positioniny meets minimum slope requirement of >1 �o? [�Yes ❑ No Comments: <br />Can BWD be pulled oul for inspeclion and mainlenan�e alter loosening thumb screw?�Yes ❑ No <br />Is BWD locked into lhe proper posilion and Ihumb screw tightened? �Yes ❑ No <br />Circle lhe BWD cov irrigat�on cover{lendscape�t�l ratfic load eanng cover (drive surface) I access halch (building) <br />Was property o�vner shown the oca i�rrof the in a e BWD? �Yes ❑ No Commenls: <br />_ __ .. <br />PropeRy Owner s Signature: <br />Installcr'S <br />Date: / ���`� <br />Dale: �l �ze /.� <br />Revision: 2 ] Friday, September 12, 2014 <br />