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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Instailation Company Name and Conlact Inic7rj_i�,��_��xs�.�c'ri �alJccas '�z5�'�'7 y�S <br /> Date Backwater Prevention device(BN'D)was inslalled: Z ry 5� Datr,lhis fonn rras rompleted: B� I ZB► 5 <br /> Installation Property Owner Name and Contact Info:��c.� �-0���y>� ���'z 3 9 � 1/Z 3� <br /> Properiy Address: //6� f'�a���� Ih'� �Jz�' �� �'�'' 9�'�� <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked'Yes'in order(or a BWD 10 6e r.onside�ed for ins�allatinn <br /> Is there a basement or level of the house lhal is at or near assumed sewer main elevalio�i?[_�es [�No <br /> Are Ihere tixtures in the house located below the upslream sewer manhole rim elevalion?� []No <br /> Is Ihe side sewer currently UNPROTECTED(rom sewer backups(doe�nol have a 3WD inslalled)?(�-}'Yes ❑No <br /> Site Inspection Checklist: <br /> A;1 items must be checked'Ves'6etore insper.fion is considered complete <br /> Was side sewer N inspected from building to sewer main? �s ❑No Condition: _ __ <br /> Does side sewer have al least t%slope from lhe building to sewer main? Q Yes ❑ No Describe: <br /> Have all building sewer drain eonnections lo the side sewer been ideidilied and located'? [�]''Yes [�No <br /> Have all property storm drainaye connec�ions to the side sewer been identified and localed? �"Yes ❑No <br /> Has property been evaluated for drainage de(iciencies wilh findinys communicaled lo property owner? ��Yes ❑ No <br /> Installation Details: <br /> Whal lype antl brantl oiBWD was inslalled at this site(Gean Clicck BWV, Grinder pump,etc.):��� C�vC� <br /> VJhere was ihe device installed(general description,altach map)?G���� ✓�i4t,�-F�9�'�9-�'P J!c{��N� <br /> Was ihere any other sewer or slorm drainage��kD mpleled in conjunclion wilh lhe f3WD work?Is so please describe:_ <br /> Installation Checklist: <br /> Are all downspouls and site drainage disconnecled from upstrearn ol the BWD'? Ycs ❑No Commr.nls <br /> Does BWD positioniny meels minimum siope requiremenl ul>1%? '�es ❑No Commenls _ <br /> Can BWD be pulled out for inspc:r,tion and maiolenancc aflcr loos�:ning Ihumb screw? [�es � �Nu <br /> Is BIND locked into Ihe proper pnsition and thumb screw tiyfilenr�ci� I"I xes ❑ No <br /> Cirrle lhe RIND r,over:irrigalion cover Qandscape area)I trafiir,load beariny cover(drive surface)1• .cess halch(ln�iliiing) <br /> Was property owner shown ihe localion of the installed B ? []'Yes ❑ No Commenis ______ _ <br /> � <br /> Property Owner's Sign� re• --_ . -- Dale: B'� Bl Z�f S _ <br /> . � <br /> Installei's Signrdure �_ � _ � Data � �_ � <br /> S <br /> - — - - /------ <br /> Revisu �� 2 1 Monday, Suplrnibcr I'�,2D]A <br />