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BACK�iIVATER PREVEnTION DEVICE �INAL <br />INSTALLATION CHECKLIST <br />1'►'1L'(`iGuil `,�C��'r� c^r ���ci� .,C',:L��f'� L i_G <br />Ir�staliation Compzny Name and Contact Inio�� �-� � (' (��: � ���� � � ��� ti-�'�i�� <br />Date Backwaler Prevention device jBV�'D) e�as installed: ����.I�— Date ihis form v,�as completed: �� S <br />Installation Pr�pe�ty O��+ner Name and Contac[ Inio: ' C f��57T.�_. ��%�_ZC-`1 -��7:5' <br />�ropertyAddress: �7(�f ��l C2/'lrl .ith°.� 4= ��F/��" ���-�:= <br />Pre•Installation Inspection Checklist: <br />All items must be checked 'Ves' in order for a Bl�✓D to be considered for insfa(lafion <br />Is there a basement or level of the house Ihat is at or near assumed se���er main efevation? � Yes ❑ No <br />Are there fixtures in the house located 6elo�v the upstream sewer ma�;hole rim elevat�on? �7j Yes ❑ No <br />Is ihe side sevrer currer�tly UNPROTECTED from sewer backups (does not have a BVJD installed)? � Yes ❑�Jo <br />Site Inspec;iun Checklist: <br />AIf items must be checke� 'Yes' before inspection is consMsred complete <br />Was side sev�er TV inspected irom building to see�er main? �] Yes ❑ No Condition: C'�'�Y� __ ____ <br />Does side sewer have at least t°; slope from the building to sewer main? � Yes ❑ No Describe: _ <br />Have all building se�ver drain connections to the side sev�er been identitied and located? y� Yes ❑ No <br />Have all oroperty srorm drzinaoe connections to the side sewer been identified and localetl? � Yes ❑ No <br />Has property been evafuated for drainage deficiencies vriih findings communicatetl to property oa�ner? t�(j Yes Ll �o <br />installation Details: <br />Ut�hat rype and brand ot BVVD was installed at ihis site (Clean Check BWV, Grinder pump, etc.): _[��-(c� �r-r I/ <br />l4�here �vas the device inslalied (general desr,riphon, atlach map)7 _��' � �Gt�C{G/'�C� �S� <br />Yl'as there any olher se�•�er or storm drainage work compleled in conjunction wtlh the BIND eror�c? Is so please describe: _ <br />------- ---- --��5� �__. —. <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream oi lhe f31�dD? [�Yes ❑ No Comments: ___ <br />Does BWD posilioning meels minimum slope requirement oi >1 %? [� 1'es ❑ No Comments: __ ___ ___ <br />Can BVVD be pulletl oul lor inspection and maintenance atter loosening ihumb screv+? � Yes ❑ No <br />Is BWD locked inta the proper osition and lhumb screw tightened? � Yes ❑ No <br />Circle the 13N�D cav : inigal,ion cover antlscape areaj I traflic load bearing cover (drive sur(ace) I access hatch (huilding) <br />Was property owner shown Ihe ocation of the installed BWD? � 1'es ❑ No Commenls. <br />� ,_ <br />Property Ov+ner's 5ignaWre: : � GU���'� ` � � �� Dale: ! ' �j ' � `,�? <br />Installer's Signature: �d-C_� _ Date: �,�f� <br />i <br />Revision: 7 i Friday, September 12, 2019 <br />