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, <br /> ' • BACKWATER PREVENTION DEVICE FINAL <br /> ,� INSTALLATION CHECKLIST <br /> -- <br /> Inslallalion Company Name and Contacl In(o: �l,�ri� r�('��LL'S i'"L. i,ti�; 1( I <br /> 11�.��._!�'( <br /> Dale Backwafer Prevention devico (BVJD)was insfaVed: ���� 45 Date this form was compleled:l y3�—!S <br /> �Inslallation.Piope�iy Oivner Name arid Contect Info'. �Ilcy, "� ���a„„4 `��� <br /> f Property Addresx� ��� �'�� A11� <br /> Pre-installation Inspection Checklist; <br /> /llf ifems musl be checked'Yes'in order for a BWD to be considered for insfallation <br /> Is lhere a basement or level o(lhe house lhat is at or near assumed sewer main elevation? �(es ❑ No <br /> Are Ihere fir,lures in ihe house located below fhe upsiream sewer manhole rim elevation? �Yes ❑I b <br /> Is ihe side sevier currenlly UNPROT[CTED irom sea�er backups(does not have a BWD installed)? �s ❑ No <br /> Site Inspection Checklist: <br /> Allilems musf be checked'Yes'be(ore inspection is considered romplete <br /> N�as side sewer 1V inspecied lrom building to sewer main? �s ❑ No Condition: ��'� <br /> � <br /> Does side sewer have at least 1%slope(rom the building ro sevaer main? �es ❑ No De cribe: <br /> Have all builtl,ing se�,ver drain conneclions to the side se�ver been idenlified and located? �es (� No <br /> 'e <br /> Havz all property slorm drainage connec:ions to ihe side sewer been ideNified and locatetl? es ❑ No <br /> Has properly been ovaluated for drainage deficiencies with findings communicated to property owner? es ❑ No <br /> Installation Details: <br /> lNhal type antl 6rand.o(13WD voas installed at this sile(Clean Check 4WU, Grindcr pump, efc.): l�I D�^�+i W�� <br /> �A�h�re was the device installed�general description,allach map)? ___�M�'� FrT��'C(�,� <br /> Was lhere any other sewer or slorm drainage work compleled in conjunr,tion wilh ihe DWD work? Is so please describe:�� <br /> Installation Ghecklist: <br /> Are all downspoWs ahd site drainage disconnecled from upslream of the BVJ ? es ❑ No Commenis: <br /> Does BWD postlioning mee(s minimum slope requirement of>1"/0? es [� No Com n(s: <br /> � --- — -- <br /> Can BIND be.pullr,d out for inspection and mainlenance afler loosening Ihum screw? � Yes (� No <br /> Is��/JD lor.ked into Ihe proper osilion and thumb s rew lightened? es ❑ No <br /> Circle Ihe BWD cover: i , ' � )/(raifc loacl b rifi9 cover(drive surface)I aer,ess hatch(building) <br /> Was properly owner shown the location of lhe inslalled BWD? _ Yes ❑ No Commenls: <br /> Pro eii Own rc 's5i na�ure:� ?�- <br /> L P Y � 9I e'. i_ _ �Dale:,_ -7 30 1� <br /> Installer's Sigiialure: I _ Dale:_�_'�J �5 __ <br /> � � � <br /> Rev�sion: 2 � I � Mnnday,Sep[emher 75, 2014 <br />