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BACKWATER PREVENTION DEVICE FINAL <br />�„ INSTALLATION CHECKLIST <br />rn�r� c��n �.�/+ :�, �r ����de sc':.z-z�, L LG <br />InscallationComp2nyNameandContactlnfo�c__; _.C•C �[_(�7,�?'�-��5�/1 �'���Tl� ��`-w,)'��_I�.�L'��;� <br />Date Bacfn:atec Prevention device (Blh'D) r�as inslalled:��� , Date this iorm e:as completed:�o%%��/ S <br />qa asa <br />Insia!!alion Property Ov+ner Name and Contact Info: ��t1 •��( ��/l ¢'aSY�� �� � �� G �11�,._-- <br />Pra;.ertyNddress: S'S�J`t ��l`.ri /j�� � � C'��_"l�'nl -- <br />Pre•Installation Inspection Checklist: <br />A�I items must 6e checkea 'Ves' in order lor a 8VlD to be r.nnsidered (or inslallahrn <br />Is taere a basement or level of the no�se that is at or near assumed seti�aer main eleval on� �,? Yes J�J� <br />Are ihere fixtures in the house located 6elo�:i ihe upstream seti:�er manhoie rim elev2tron? ,`�S'es ❑�Jo <br />Is tne side seerer currently UNI'ROTECTED irom se•:ver backups (doe� not have a B'+VD installed)? [�Ye; j_f Dlo <br />Site Inspection Checklist: <br />�I! items must be checked'Yes' befae inspecGon is considered complete /� <br />1'ti�as side sev+er TV inspected from builtling to se�ver main? ��Yes ❑ �\o Cond�t:or. __ t"'7� ______ __. <br />Does side see+er have al least i°6 slope irom the buittling lo see:er main? [�:Yes ❑ No Describe: <br />Have aIi buiiding se�:�er drain connections.to Ihe side see»r heen i�enti ied and located? �i} Yes ❑ No <br />I'a:�e a l p;operty storm drainage connections to ihe sh�e see�er heen idenlified and Iccated? �l'•�s ❑ No <br />Ha; p�oparty been evaluated for drair,age defic!encies e+�th findings communicated to property o^mer? (�1'es ❑ No <br />Installation Details: <br />What type and brand of Bl�'D eias insta!led at this site (Clean Check BV��V, Grirder p�u,mp, etc.):��f�,' fiCD'� ��' <br />�iVhere ti�,as the de��ice insialled (yeneral desc�iption, attach map}7 _�� (,�.;�7��t' '1?�'�1 _- �.S�Y,td.�7_' <br />1?'as there an� other sewer or storm drainage vrork compleletl in conjunclion eiith ihe E3WD vrork? Is so please describe: <br />k /�(�/�/ <br />�Y'S- <br />Installation Checklist: <br />!vr_ a�i doemspouls and sile drainage disconneeted trom upsiream of ihe f3WD? � Ycs ❑ No Comments: __ <br />Dc;es Bl4'0 positioning meets minimum slope requirement ot >1 °o? �'es � i No Comments: __ _____ <br />G�an BIND be pulled out for inspection and maintenance after loosening Ihumb scre�v? �1 es ❑ No <br />Is BWD locked into the roper-position and thumb scre��� tightened? ��es ❑ No <br />Circle the BWD co;�.r. irngation cover I�scape area)1 tra(fic Iuad bearing cover (drl��e surtac.e) ! access halch (buitding) <br />':?'2s property ovmer s e loca6on of the installed BIND? �'es ❑ No Commenls _ <br />Property Owner's Signature� 7/��,�'"i. Oate: _?�' `(7" u��% <br />/ <br />Inslal!er's Signature: _ _ � ��� Date: a �� _ <br />1 1 fnda Se temher 12, 2014 <br />✓ <br />ftevision:2 � Y� P <br />