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BACKWATER PREVENTION DEVICE FINAL <br />I�VSTAL�ATION CHECKLIST <br />Installalion Company Name and Contact Into: /��o/% ��r� /' C3i' n �� 3°Sr7 —/SUi <br />✓ <br />Date Backtva`,er Prevention device (BWD) was ins�alled: / ZZ- /s'Dale this form was comp!eted: ��Z 3�/,1� <br />Installation Property Ovmer Name and Contacl Inio: � ���n �G/� S-f e r7� er <br />PropertyAddress: _ (;/�—��S G/��+ O <br />Pre•Installation Inspection Checklist: <br />All ifems must be checked 'Yes' in order lor a B WD to 6e considered for installafion <br />Is Ihere a basement or level o( the house that is at or near assumed sewer main elevation? �Yes ❑ No <br />Are Ihere 6ziures in the house located below the upsiream sewer manhole rim elevation? �Yes ❑ No <br />Is tha side ser�er currenUy UNPROTECTED (rom sewer backups (does not have a BVJO inslalled)? �s ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete <br />4Vas side sevrer TV inspecled from buildin9 to sewer main? �Yes ❑ N�o /Condition: <br />Does side se�ver have at least 1`/o slope from 1he buildi�g to sewer main? lQ Yes ❑ No Describe: <br />i <br />Have aii buiiding sewer drain connections to lhe side ;ev�er been idenlifed and locatetl? � Yes P:o <br />Have all properly slorc� drainage connections to the side se�eer been idenGfed and located? Yes ❑ No <br />Has pmperty been evaluated (or drainage deficieneies �vith fndings communicated to properiy owner? �es ❑ No <br />Installation Details: <br />What type and brand of BVJD was installed at lhis si _�leantiheck BN nder pump, etc.): <br />WF�ere was the device installed (general descriptio ,-attachaaep)�/7!f v�, wc,Y <br />Was there any other se�ver or storm drainage work completed in canjunction with ihe BWD �vork? Is so please describe: _ <br />Installation Checklist: <br />Are ali do�Nnspouls and site drainage disconnected from upslream oi the BWD? � Yes ❑ No CommAnis: <br />Does BWD positioning meels minimum slope req�irement of >1 %? ��Yes ❑ No Cornmenls: <br />r <br />Can BWD he pulled oul lor inspe�lion and mainlenance a(ter iooseninp U�umb scre�v?/(_] Yes L] Nu <br />Is BIND locked in�o ihe proper position and �humb scre�v tightened? Q Yes [� No <br />Circle the BWD cover. irrigalion cover (landscape area�raNc load earing cove� nve su ace access hatch (building) <br />Was property ovmer sho�vn ihe loea ion of Ihe inslalled B':V6'f Yes ❑ No Comments: <br />1 <br />Property Owners Signature. � � Date: �?�2 � <br />Installcrs Signaturez Dale: �2 ��/ .� <br />— _..., % <br />Revision: 2 1 Friday, September 12, 2014 <br />