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� <br />� <br />BACKWATER PREVENTION DEVICE FINA� <br />INSTALLATION CHECKLIST <br />cccn ��nt� � <br />Installation Company Name and Contact Info:Jr> 4-•� (t[ Ce. " -� •° ' "' " <br />Date Baektaater Prevention device (BWD) e�as installed:�j �, Date ihis form was completed: ,� l�_ <br />installalion Propedy Oe:ner Name and Contact Info�L' 1'\ (�P,YI �lilD/J o1s a7.�� -l�7�" <br />Property Address. <br />Pre-Installation Inspection Checklist: <br />All items must 6e checked 'Yes' in order for a f3WD to be considered for installafion <br />Is there a basement or level of Ihe house that is at or near assumed sewer main elevation" . Yes ❑ No <br />Hre there fixtures in Ine Iwuse located below the upsiream sewer manho;e rim elevation? � Yes ❑ No <br />Is the side sewer currenfly UNPROTECTED irom sewer backups (does not have a BVJD inslalled)? Yes ❑ No <br />Site Inspection Cfiecklist: <br />All ifems must be checked'Yes' b:iore inspection is considered compfete /, I <br />NJas side se�•+er TV inspected from building lo seiver ma'n? �Yes [� No Condition: (�d�7� <br />Does side sewer have at Ieas11% slope irom ihe building to sevrer main? ONes ❑ No Describe: <br />t'�ve ail building sevrer drain connections lo lhe side sewer been identified and located? ❑� •Yes ❑ No <br />Have all properly storm drainage connections to the side sewer been identified and located? (� Yes ❑ No <br />Has property been evaluated tor drainage deficiencies w�th findings communicated to oropedy oemer? 0-Yes ❑ No <br />Installation Details: <br />Whal rype and brand ot BWD tvas inslalled at this site (Cfean Check BUt'V, Grinder pump, etcJ: �j <br />�PJhere was Ihe deviee installed (general description, atlach map)? ��J��(L'�r1�(.{� �� � �r�' <br />VVas lhere any other see+er or storm drainage �ti�ork comple�te�d� �in c�onj�unction with ihe BWQ work7 Is so please describe: _ <br />��`a-�-L(C <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected trom upstream of the BWD? D�Yes ❑ No Comm�nls� <br />Do�:s BIND positioning meets minimum slope requirement of>1°/a? [�-Yes ❑ No Comments: <br />C in B�VD be pulletl out for inspection and mainlenance afler loosening thumb s�rew? ❑ Yes ❑ No <br />Is BWD loctied into lhe pra er ppsiliop and iftumb scre�v tightened? [�Yes ❑ No <br />Circle the BWD c� r. ungat� 3Rdscape area) /lraffic load hearing cover (drive surface) / access halch (building) <br />b'Jas property oe�ner shown Ihe locaticn of Ihe inslalled BWD? _[�yes� No Commenls: <br />� �— <br />Properiy Owner's Signatu(e: �� .- .rh Dale: �'� ` � <br />G_ <br />I�;}aller's 5ignature: Dale: ` <br />Revision: 2 � 1 Friday, Septembcr 12, 2014 <br />