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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Ins(allalion Company Name and Coniacl Info: ������U/ <br /> Date Backv�ater P�sveNion deviee(B4VD)was installed: � I � � I.� Date this iorm was comp!eted. � 1'I I I'-=i <br /> Ins'allalion Property Ovrner Name and Con�a�l Info: CI1Y1�Up Sl C��X.� `�� � — <br /> Praperiy Address:_ ��'�� �-1 ti�G�'�� ' � "' <br /> Pre-Installation Inspection Checklist: <br /> All ifems must be checked'Yes'in arder/or a BV'D to be considered lor installation <br /> Is tnere a hasement or level o(the house that is at or near assumed sewer main elevalion% �]Yes ❑ Nc <br /> Are there f!Aures in the house located belo�v the upstream sevrer manho'e rim elevalion? �f Yes [� No <br /> Is the side sewer c;;rrently UNPROI ECTED irom sew=r hackups (dees not have a BWD installed)?� Yes [� No <br /> Site Inspection Checklist: <br /> !+ll items must be checked'Yes'be(ore inspsction is ccnsidered compiete <br /> Was side sewer TV inspected from buiiding to sevrer mair.? �Yes ❑ No Condition: <br /> �oes side searer have al least 1°o slope irom the building lo sewer main? �j 1'es ❑ No Describe: <br /> Have all �uildicg setver drain conneclions fo the side sewer been identified and located? �Yes ❑ No <br /> Have a!I property srorm drainage conneclions to the side se�ver heen identified and lo;,ated? �Yes ❑ No <br /> Has property been evafuated for drainage defciencies wilh findings communicated to property owne�? �Yes ❑ No <br /> Instaliation DeWils: � <br /> What type antl brand oi BVJD tivas inslalled at lhis site(Clean Check B�W,Grin�der pump,etc.): S �rn ri C�-�`� <br /> l'Jhere •�as the de��icg installed (generai description, attach map)? �l,l:�,�l(�-�- � �1 A/l.p � <br /> �G� 1�G�V�- _ <br /> Was there any other se+ver or slorm drainage work compleled in conjunclion v:ith lhe BWD work? Is so please descrihe:_ <br /> ��`� <br /> Installation Checklist: <br /> Are all dotimspouts and sile drainage disconnecfed from upstream of the BWD? �Yes ❑ No Comments: <br /> D�es BNJD p�sitioning meets minimum slope requirement oi>1%? �I Yes [,No CommeNs: <br /> Can BWC be pulled out`or inspeciion and maintenan�e a(ter loosening fhumb scre�v? �) Yes ❑ No <br /> Is BWD locked �nto the ro osition and ihumb screw tlghtened? �.]Yes ❑ No <br /> --�� <br /> Circle the BWD cove . i alion cover(landscape area affc load bearing cover(drive surface)/access hatch(building) <br /> VJas property owner shown ihe location of ihe mslaited 81ND� �]Yes ❑ No Commenls: .— <br /> PropeRy Ow,ner's Signature:���',_.�___.��,�� Date: '� ��/�� <br /> installers SignaWre`����� � �- _����__ Oale: � � �/I.� <br /> Revision: 2 1 Friday,Sepiember 12, 2014 <br />