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BACKWATER PREVENTION DEVICE FINAL � <br /> �. INSTALLATION CHECKLIST <br /> ;nstal!atinn Company Name and Con(act Info l��%nt% 1 L✓..��;,,.�o ( �i�C,• - �Y7(� - C�1 Z`7� <br /> Date backwater cev,ce�B4VD)was installed:�� Dafe this form v�as comp'eted �' �l /` � <br /> 'nslallation ?roper�y Oemer Name and Conlacl inb: CS �=�� �v_�i ' <br /> PropertyNCdress:-- _ -�9U1 _}-\i�� �_t� �-liir __(s.VC�v?c. , r (i��1- _ <br /> Pre-Installation Inspection Checklist: � <br /> A!!rtems rn!ist be chec�ed 'Yes'in order lor a Ql4�D to be consiaered(or instaliabor� ; <br /> Is there a basemenl or Ievel of`he house that is at or near assumea ser;er main e:evatior�? � Yes �] No � <br /> hre there `xtures in the ho�se located belov�the upslream sewer manho!e rim elevation7�Yes ❑ No <br /> Is ih�side ser;er currently UNPROTECTED`rom sev+er ba��:ups (coes not have a DV�'D insta!led)� � Yes ❑I�o : <br /> Site Inspection Checklist: <br /> Aii ite�r,s must be c�;eckeo 'Yes'belora inspecfion is ccnsidered ccmp;ete <br /> CJ2s s�de se�ver TV inspec(ed irom bwld�ng to sewer main7 [�Yes ❑No Condition: C(K ls�,Nr.i! {�'C_ <br /> Does side setiver have at least 1% slope from the buiitling to sev;er main? (�Yes ❑ No Describe <br /> Have zll build�ng ser�er drain connections to the side se�ver been ident�fed and located? ��Yes ❑ No <br /> Have all property storm drainage connecli�ns to the side se���er been idenlified and located? U Yes ❑ No i <br /> Has property been evalualed for drainaoe deticiercies with findings communicafed lo property ownerl (�Yes ❑ No � <br /> Installation Details: <br /> Whal type and brand c(BN�D was installed al this s�le (Clean Check BVJV, Grinder pump, elc.): C( c:rN C N �c� ��"�� . <br /> I <br /> U�'"ere�nas ihe device mstalled(general description,attach map�7 _3r-'r 9�N,a �i:��.� c Gc�a.0 o��T , <br /> ��— � <br /> V�'as ther*m any olh^r s�wer or storm dra!nayc work completed in conjunclion�sith the ADWD�vork? Is so please describe: � <br /> i <br /> Installation Checklist: ' <br /> I <br /> Are all downspouls and site drainage disconnected frcm upstream of ihe BVJD'? �j�Q,Yes ❑ No Comments:__ <br /> � <br /> Does BWV positioring meet minimum slope ieruiremeni oi>t%? I�Yes (—� No Ccmments� __ � <br /> Can Bl4N be pulled out (or inspection and maintenance after loosening thumb scre�v7 q Yes []No � <br /> Is 414�V lockr.d into the proper posilion and fhumb scree�tightened? �j Yes ❑ hb <br /> C�rcle,he I3lNV�over: imga6on cover(landscape area)1 tra�fic load bearing cover(drive surlace)! ccess hatch 'building) <br /> Was hon�eowncr sho�vn the locafion f lLe 'ns ed kBWD? Yes ❑ No Comments <br /> Propedy O�vner's Signat _ . Dale. � � �� _ <br /> Ir:slaBer's Signalure:_s_�3, C,/"� Date: `I 6 � <br /> ` <br /> Revisiun 2 1 Monday, September O8, 2014 <br />