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BACKWAT�R PREVENTION DEVICE FINAL <br />INSTALLATION CH�CKLlST <br />Installalion Company Name and Contact Info: O U vv � <br />Dat� Baclnvater Prevention device (BYI'D) was inslalied: (�- s' 1 S Date this form was compleled:s�' �Z I S <br />Installation Properfy Owner Name and Cont�cl Info: �`'� f��f � <br />Pro�erty Address: ��ih � C7 z+�G� v�12 <br />Pre•Installation InspectionChecklist: ' <br />�411 items must be checked'Yes' in order for a BIND to te considered for i��stallafion <br />Is there a basement or Ievei �i the house that is al or nezr assumed se�ver main elevation? [�Yes ❑ N� <br />Are there fixtur2s in lhe house located bzlow.the upstream sewer manhole rim elevalion? [�] Yes ❑ t�o <br />Is tne sitle sewer curtently UNPROTECTED from setiver backups (do°s not have a BWD installed)? � 1'es ❑ No <br />Site Inspect!on Checklist: <br />All item;, must 6e checked'Yes' be(ore inspection is considered complete <br />Was side sewer N inspected from building !o se�ver main? � Yes ❑ No Contlition: <br />Does side sewer have at lezst 1% slope f!om the building to sevr�r main? � Yes ❑ No Describe: <br />Have all building sewer drain conneciions to the side s°�ver heen identi5ed and located? [� Yes ❑ No <br />Have all property stortn drainage connections to the side serer Ceen idenGfied and focated? [�Yes ❑ No <br />Has property been evaluated for d2inage deficiencies with fndings ammunicated to properf;� o�vner7 4�Yes ❑ No <br />Installation Details: <br />What type and brand of BWD �vas insta{led at this sife ( lean Check B Grinder pump, elc.): <br />Whe�e e;as lhe device instailed (general description, attach map)? <br />o� - _ - _ 4,:��• <br />Was there any other sewer or slorm drainage work comple\ed in conjunc_ h_'on ith the BUt�D work7 Is so please describe: _ <br />Installation Checklist: <br />Are all dovrnspouts and site drainage Jisconnected trom upstream ot the BWD7 f� Yes <br />BWD 't' ' eets minimum slope requirement of >1%? ¢] Yes ❑ No <br />❑ No Comments� <br />Comments: <br />Does posi ioning m <br />Can 8WD be pulled out for inspection and main(enance after loosening thumb screvr? �] Yes ❑ No <br />Is BWD locked inlo the proper.posilion andilmm� rew tightened7 �1 Yes ❑ No <br />Circle ihe BWD cov imga�on cover (landscape area)1 affic load bearing cover (drive surface)1 access halch (building) <br />�____ _, <br />Was property owner shown ihe localion o e mstalled BWD? [, Yes ❑ No Comments: <br />Property Owner's Signature: Date: _ <br />InstallersSignature: --- - Date: � -��--�s <br />Revision: 2 1 Friday, September 12, 2014 <br />