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� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Comoany Name and Contact In'o �-+��-o (�l,��w�t��wL, ?�t:• -�(;�i., •r, 9 z"i <br />Da(e Back�aaler Pre��ention device (BVJD) eras installed: �i'' -- i�-/y Date this fo�m a:as completed �i -/`7 -i 4 <br />Installat,or Property O�+mer Name and Conlacl info: <br />Property Acdress: <br />Pre•Installation Inspection Checklist: <br />!df items must be checked 'Yes' ir, order for a 8WD to be conside�ed (or installation <br />Is there a basement or level of the housc that is at or ncar assumed sewer main elevalion- � Yes ❑ No <br />Are there frtures in ihP house located belo�v Ihe upstream se�.ver manhole rim elevalion? � Yes ❑ No <br />Is ine s� ie sewei wrre�tl, UtJPR�TECTED from sewer backuos (does not have a BWD installedJ? (� Yes ❑ No <br />Site Inspection Checklist: <br />liil items musf be ciiecked'Yes' belore mspec6on is conside�ed complete <br />V�'as side see�er N ir,oected from nuilding ta sewer mair,7 � Yes ❑ No Condition� <br />Ooes side sewer have at least t°h siope from Ihe building to sewer main7 �] Yes ❑ No Describe: <br />Ha��e all buildin, sewer drain eonnections in Ihe side se::�er been ident�ed and locate�? �Yes ❑ No <br />Have all property si�rm drainage conne�tions to ihe side sewer been identified and located? �f Yes ❑ No <br />H2s property been evaluated for drainage defieiencies with f�ndings communicated ".o property owner? (� Yes ❑ No <br />Installation Details: <br />�A'hat type and brand ol B'+VD was installed at ihis sile (Clean Check BNN, Grinder puntp, etc.). ('�,.i C{icZ^!c' ���' i� <br />Where was the device installed (general descriplion, attach mapj? _�;���'i n�: i�l= �, 0-1 <br />�4.-��, rc- µ✓�� <br />'Nas lhere any olher sewer or slorm drainage work compleled in conjunclion ��ith lhr. BVJD v.�ork? Is so please describe: [_v <br />Installation Checklist: <br />Are all downspouts and sile drainage disconnected irom upstream of the B'ND? � Yes ❑ No Commenls <br />Does BVJD posilioning meels minimum slope requirement of >1%? [� ti'es ❑ No Commenls. <br />Can BNJD be pulled out for inspeclion and maintenance a(ler loosening thumb screti�? jRf Yes [� Nu <br />Is RIND locked into the proper position and ihumb screw tightened? � Yes ❑ No <br />Circle the BN'D cover. irrigation cover (landsc��pe area)1 traKc load bearing cover (drive surface) I access halch (building) <br />Was property rn+ner shown ihe locatio ' stalled BN(�? �i�f Yes ❑ No Commenls: <br />Property O�mer's Signatu `y� Oate: <br />Installer's Signature: � ��ir_� �—� _ Date: 9— /%�� �� <br />Revision: 2 1 Tuesday. September iG, 2014 <br />