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BACKINATER PREVENTION DEVICE FINAL <br />Q. INSTALLATION CHECKLIST <br />Instalia(icn Company fJame 2nd CcNac� In`a ���� .A�1'��,� k�� .(�i��� ��-� <br />Date Back:vater Prevention device (B'n'O) �vas insta led ��� Dale :n s(orm e:as complefed:�� <br />Instailation Property Owner Nzme and Contact In(o ����,� � i�1�r��-�lr� <br />Property Address <br />Pre•Instaliation Inspection Checklist: <br />dll ilems must br,- cfar.ke� 'Ves' m order for a BWD to be consinered /or mstallation <br />;s there a basement o• le��el of tiie house tnat is at or near assumed se��,�er main elevation? � Yes ❑ Vo <br />;�re Ihere fixfires in lhe house Iccaled beloe, Ihe upsfream ,evler manhole rm elevation7 � Yes [� ^do <br />Is �!���e si�'e sc,�ar curre:"ly �JPJPP.CTEC �`[D from sewer b2c4ups (does nol have a B�ND installed)? j�Yes ❑ No <br />Site Inspection Checklist: <br />,4f! items mus! be checked 'Yes' be(ae ,�ispectron is consicered compiete <br />':`: as side se:ver T�l inspected irom build����g ?o sevaer main7 [�ZI Yes ❑ I�o Condition:l�c� i3�F _ Plt�i,:}- <br />Does side seu�er have at leasl 1% slope from Ihe bu lding to sewer main? �Yes ❑ Wo Descrihe: _ <br />-I ava all buiiding se�r�er drain connecbons to ihe side sewer be2n idenli`ed and located7 �] Yes ❑ Ido <br />riave a!I property storm drainage conneclions to the side se�ver been identifietl and located? � Yes ❑ No <br />Has oroperty been evaluated for d�ainage de(iciencies �vilh imdings comm�nicated to properly oeme!7 [j�( Yes ❑ No <br />Installation Details: <br />?lrna; type and brand o` RVJD was ins�alled a! ih�s site (Clean Check 61NV, Grinder pump, e;c )�,�.,.�S1..nr lL <br />1''�ere eras Ihe device insla!,ed (gereral desc!iption, altach map)? iN�qg•�ws�n\ �.ti Accces'� <br />5i���- �u :c `�h l�cM;t — <br />��`Jas there an� olhe� sec�er or sform drainage erork completed in conjunction :v�in t'ce Gl4�D work? Is so please descr�bc �� <br />�✓SSi___CCt,eNn.r,t_ r.c��iZLL <br />Installation Checklist: <br />i�re ali do�:ms{ ouls and sile d�ainzye disconnect�d from upslream of the BI�VD? (� Yes ❑ No CommeNs'. _ <br />�oes 81ND posilioning mecls minimum slnpe requiremenl o` >19„? l�(`i Yes �__] tdo Comments <br />Can BWD be pulled ouf (or irspecl�on and mainlen2nce afle� loosenin;� ihumb screw? �j� Yes ❑ No <br />!s 641'D Incked into Ihe proper posilion and thumb scre�v tightened? ,� Yes ❑ No <br />C�rcle the DWD cover: irriy2tion wver (landscape area) ! Ira(!ic load bearing cover (drive surfa�e) I access hatch (building) <br />."das property owner shovm Ihe location of the alled 6WD� ` Yes ❑ No Commenlsl��S��4 Ac�L.rL Rs�i <br />P�operly Ovaner's Signatu � - Dale � � ! �5 / <br />Instalier's Signature: i � Date ..�-- ��� �� <br />� <br />ReciS�oti 7 ' 1 Fnday, September 12, 2U1� <br />