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� <br />� <br />BAC4(WATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />t'►'lEri Ccen `�(�t� G <br />installation Company Name and Conlact Info:Jf,� �•� u � r r c�t �`��.�rr �rv��' ��.�' <br />Date Back�vater Prevention device (BWD) tvas installed:�� � Date this form was <br />Inslallalion Property Owner Name and Contact Info: <br />Property Address: <br />i <br />L <br />Pre•Installation InspecGon Checklist: <br />All items must 6e checked 'Yes' in order for a BWD to be considered for installation <br />Is ihere a basement or level of 1he house that is at or near assumed sewer main elevation? [�Yes ❑ No <br />Are Ihere fixtures in the house located below the upstream sewer manhole rim elevation? (�Yes ❑ No <br />Is the side se�ver currenfly UNPROTECTED from se�ver baekups (does not have a 8WD instailed)? �'Yes ❑ No <br />Site Inspection Checklist: <br />All items rnust be checked 'Yes' before inspection is consrdered complete _ I <br />INas side sewer TV inspected from building to sewer main? [�Yes ❑ No Condition: �CLI� <br />Does side sevoer have at least 1%slope from Ihe building to sevaer main? [�Yes ❑ No Describe: <br />Have all building sewer drain r.onnections to the side sewer been identified and located? �'es ❑ No <br />Have all property stor.m dr�inage conneciions to the side sevder been identified and localed? ,�Yes ❑ No <br />Has property heen evaluated for drainage de6ciencies with findings communicated to property o�vne�? �Yes ❑ No <br />Installation Details: <br />What type and brand of 8WD was inslalled at ihis sile (Clean Check BWV, Grinder pump, etc.): �F�[I✓' C1�' <br />Where was the device installed (general descriplion, attach map)? SE'P���{'ec�tl�_e�- �i'S_t�(.t�L� <br />Was there any other se�ver or slorm drainage work eompleted in conjunclion �vith the E3WD work? Is so please describe: _ <br />Installation Che�klist: <br />Are all downspouts and site drainage disconnecied from upstre„m of the 8WD? (�Yes ❑ No Comments: <br />Daes BWD posilioning meets minimum slope requirement oi>1�;�0? �Gj Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after Ioose�ing thumb screw? �Yes ❑ No <br />Is BIND locked inlo the proper posilion and ihumb screw tigMened? �'1'es ❑ No <br />Circle the BWD cov r. irrigation cover ndscape area) ! traffc load bearing cover (drive surtace) I access hatch (building) <br />Was property oevner shown <br />Property Owner s Signature: <br />Inslaller's Signalure: <br />ation o he installed BWD? (�Yes ❑ No <br />/ ��' �� <br />Comments: <br />Date: �� — � y — �5 <br />Dafe: ,� ti <br />v w 1 Frida Se tember 12, 2014 <br />Revision:2 1'� P <br />