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BACKWATER PREVENTION DEVICE FINAL <br /> �. INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: ��'�/` P�+�✓�^h'' � �3G- <br /> Date dackviater Pre!�ention device(B�L�D)was installed:JZ- n�y��N _Da e this form�:as completed: � ' �U- 1 f <br /> Inslallalion Property Ovmer Name and Contact In(o: Mc.��c G-I oz�c `l�S 3��f �v�H <br /> Propert,Nddress 1 �.z � �'�-� �_ f�� __. <br /> Pre•Installation Inspection Checklist: <br /> All items must 6e checked 'Yes'in o�der(or a BbVD lo be considered for installauon <br /> Is there a basement or level of!he house that is at or near assumed se�ver main elevation? � Yes Lj No <br /> Are there fixtures in ihe house located beloe�ihe upslream se;ver manhole rim elevation?� Yes ❑ No <br /> Is lhe sitle sei:�er currently UNPROTECTED irom sev:er bar,kups (does nol have a 64VD �nstalled)'�Yes ❑ No <br /> Site Inspection Checklist: <br /> fill dems must be checked'Yes'6e%re inspection is considered complete <br /> INas side sev�er Tl�inspected from building to sev�er main? I�J Yes ❑ No Ccndition: <br /> Does side setiver have at leasl 1°'o slope irom the building to sewer main? �Yes ❑ No Describe: <br /> Have a'I building se�ver drain conneclions to ihe side sew2r been identified and located? �Yes ❑ No <br /> Have all pwperly storm drainage connections to lhe sitle sewer been identilied and located? �'Yes C No <br /> Has property been evaluated for drainage deficiencies vrith findings communicated lo property o�.vner? [�'Yes ❑ No <br /> Installation Details: <br /> What type antl brand o(BWD was installed al this site(Clean Check BWV, Grinder pump,elc.): ���t ���= � 2 �cc.� �t <br /> UJhere aras the device installed (general descriplion, altach map)? h�-, tic.��,�,.�.f- �b. �u�� b., <br /> �../ac4 � 19�X <br /> 1Nas there any other se���er or storm drainage��aork completed in conjunclion with lhe BN1D avnrk? Is so please describe: _ <br /> � �� � <br /> Installation Checklist: <br /> Are all downspouts and sile drainage disconnected from upstrcam of Ihe BWD? '�C Yes ❑ IJo Cornmenls: ___ _____ <br /> Does BN�D posilianing meets minimum slope requirement o(>t°a? �Yes ❑ No Comments: <br /> Can BIND be pulled out for inspeciion and mainlenance aller loosening Ihumb screw? �Yes ❑ No <br /> Is 8WU locked in�o the praper position and ihumb screvr tightened? [�Yes ❑ No <br /> Circle the BWD cover: irrigatien cover(landscape area)I lra(fic load bearing cover(drive surface)1�e ess halch(buil <br /> VJas property owner shown the location of the installed BWD7 �Yes ❑ No Commenis: <br /> Property Ov.ner's Signature: Dale: <br /> Installer's Signature: �'�'l r�/�-- Date: � ' �� ' �5 <br /> Revision: 2 1 Friday, September 12, 2014 <br />