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BACKWATER PREVENTION DEVICE FiNAL <br />E,, INSTALLATION CHECKLIST <br />fie • � 4C_';;ll� <br />Installation Company Name and Conlact info� ��}1N �'1 ��""` `"�"� ti�'��r �`"r-��; �� �- l��'`� <br />7ate P,3ck.:�ater Prevenlion device (B:4�D) �vas installed: � I Date this torm was compteied: � S <br />�s�allation Property O�aner Name and Contact Info 1,�1 LS.I Cc,4'Y1 L�1{C�:-� ���a—��� ���- <br />'r;.FertyAddress: Q I q �-itn�, i-( � il`T �� X�[.��. L ��( <br />Pre-Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a B WD to be considered for installafion <br />Is ihere a basement or level oi the house tha! is at or near assumed sevrer main elevation? � Yes ❑ No <br />Nre there fziures in the house loeated be!ow the upstream seeier manhole rim elevation? [�Yes ❑ No <br />Is the side sewer currently UPIPROTECTED from se�ver backups (does r.ot have a BV�D installed)? �"1'es ❑ No <br />5ite Inspeclion Checklist: <br />All ifems must 6e cl;ec;ed 'Yes' be`ore inspection is consid2red compfete <br />!Nas side ser:er TV inspecied from 6uilding to sev�er main? [�jYes ❑ No Condltion �C� <br />Does side sev�er have at leasll% slope Irom ihe building to see:er main? �'Yes ❑ No De�cribe: ___ <br />Have ail building sewer drain connechons to Ihe side se�ver been identified and located? �Yes ❑ No <br />Have all pwperty s[orm drainage connections to the side see�er been identified and located? �Yes ❑ No <br />Has property been evaluated lor drair.age deficiencies v�ith findings communicaled to properly o��mer? [�(Yes ❑ No <br />Installation Details: /1� <br />�Nhat type and hrand of BWD �vas inslalled al ihis site (Clean Check Bl1�N, Grinder pump, etc.): j�t�('-�1,r �l`cc ,; <br />4Uhere ��ras ihe devic� instalied (general description, attach map)7 �" /' r% �r' �%��'� �-� ��-t�T <br />Nlas there any other se�ver or storm drainage v�ork compleled in conjunction e+iih Ihe BN'D tvork? Is so please descnbe: _ <br />— -- --�-'N--'�-''-- ---- <br />Installation Checklist: <br />Are all do��:nspouts and site drainage disconnected from upstream of the BWD? �(Yes ❑ No Comments: _ <br />Does BWD positioning meets minimum siope requirement of >1%? [�(Yes ❑ No Commenls: _!__ _ <br />Can BWD be aulled nut for inspection and maintenance afler loosening Ihumb screw� �)(] Yes ❑ No <br />Is 81�'D locked into Ihe prope�sition and ihumb screw tightened? � Yes (� tdo <br />Circle the BWD cover. ngalion cover I ndscape area) I iraftic load bearing cover (drive suAace) I access hatr,h (builAing) <br />�_ _ � <br />!Mas prope�ty o:�mer sho:+n�i�ie localion of the instailed BNlD? (�Yes ❑ No Comments: ___ <br />Property O��mer's Sig <br />Installers Signalure <br />Revision: 2 <br />Date: ���-=J/ - /,<� <br />Oate: � - � � '- Z� ( .5 <br />lay, Septcmber 12, 2014 <br />