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4 BACKWATER PREVENTION DEVICE FINAL <br />n INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: M 0C I �,I t Iry "v q2 O <br />Date Baclavater Prevention device (BV!Dt was installed: —3D- (S Ate this form was Ampleted: <br />Installation Proped}' C;vner Name and Contact In!o: <br />Le s j <br />/e n <br />` ( S r-/ '? ( 0 1-2 o C-, <br />Property Address: 3 y! -7 Cs2 n � <br />(+v� <br />( -H <br />(✓11 59-c .ot <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a 131"D to be considered for installation <br />Is there abasement or level of the house that is at or near assumed sewer main elevation? �]C Yes ❑ No <br />Are there Fixtures in the house located below the upstream sewer manhole rim elevation? g Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a MID installed)? ❑l Yes []No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete <br />Was side sewer TV insaecled from building to sever main? ® Yes ❑ No Condition: /yc' LJ <br />Does side sewer have at 16rst 1% slope from the building to sewer main? ; yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? VdYes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? WjYes ❑ No <br />Has property been evaluated for drainage defirencies with findings communicated to properly owner? ® Yes ❑ NO <br />Installation Details: <br />What type and brand of Mil) was installed at this site (Clean Check MV, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? _ fit H i k0 h.v <br />Was there any other sewe[ or sJorm drainage work completed in conjunction with the B11M work? Is so please describe: <br />Installaflon Checklist: <br />Are all downspouts and siie drainage disconnected from upstream of the BVdD? UC Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? © Yes ❑ No Comments: _ <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ETYes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? N Yes ❑ No <br />Circle the BWD cover. irrigation cover (landscape area) L!�Mc load bearing cover (drive surface ? access hatch (building) <br />Was property owner shown the location of the installed BWD? Z] Yes ❑ No Comments: <br />Property Owner's Signature: Date: _ <br />Installer's Signature: /M _ Date: <br />Revislon: 2 1 rvlondav, September 15, 2014 <br />