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� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Inslallation Cornpany Name and Conlact Infc <br />Dale back�vater device (BUJD) was installed _ <br />Inslallation Prc,�erty Ovmer Name and Conta� <br />Proper!y Addrees ����[� : <br />� <br />Info: <br />r— <br />Dale this form �vas completed .� �Z�—/� <br />Pre-Inst..lialio�� Inspection Checklist: ' <br />All itcmz� musl be checked 'Yes'rr� order (or a B�✓G to 6e considered for installatiorr <br />Is fhere ,� basemerit or leve! o( Ihe hnuse thzt is at or nea assumed sewer main elevation? � Yes ❑ No <br />Ara tn?re bxlures in ihe �'�nuse located belo�v thz upslream sewer n�anhole rim etevalion� � Yes ❑ No <br />!s Ih�� side se�ver currenUy UNPROTECTED irom sev;zr bac<ups (does not have a 64VD installed)?� Yes ❑ No <br />Site !ns� ection Chec!•lisl� <br />All items must be checkea 'Ves' be/ore inspection is consideiPd compfete <br />l^,�as s;de se�ver TV inspectco from buildma to sevrer main7 �Yes ❑ No Condition: <br />Do�s side setiver have at least 1°/o slope (rom ihe huilding to se�ver main7� Yes ❑ No Descrihe: <br />Have all building sewer drain conneclions to ihe side see�er 6e� , �denlife a�, i localed� � Yes ❑ No <br />I lave all preoedy slorm drainage conneclions tu the side se:ver been identified aad located? �[] Yes ❑ No <br />Has property been evalu2�ed for drainaae deficiencies �vifh findings communicaled to pronerty o�,vner?,[ff Yes ❑ No <br />Inslallation Details: <br />Whal type and brand of B!ND �v�is insfalled a! Ihis site (G^an Check BWV, Grinder pump, elc.): <br />lNhere mtas Ihe device installed (general descriplion, attach map)7 �� S��E <br />Ydas U�ere any other sev,er or <br />Insta;iation Checklist: <br />drainage work compieled in conjunction �vith lhe ABWD ;aork7 Is so please descri6o <br />Are all dc��nspoufs and si,e dramage disconnected (rom upslream oi the B1ND? � Yes ❑ No Commenis <br />Dces OWV positioning meel minimum slopc roquirement of >1 %7 �]l'es ❑ No Comments: _ <br />Can f3WV be Fulled out (or inspeclion and maintenance after loosening lhumb screw? �� Yes ❑ IJo <br />Is R:��N locketl inlo the proper position and thumb screiv liyhtened? �Yes ❑ No <br />Cucle Ihe f3WV cover irri,3lien cover (landscape area)1(raffic load bearing cover (drive surface)1 access hatch (building) <br />Vvas homeowner shown ihe localion o( ihe installed A6WD? � Yes ❑ No Comments: <br /></� 1// �' <br />Property Ovaner's Signature __ _ _-� `'�''� Date: � ~ `� �� <br />� � n / � <br />�nslaller's Signature: _ Date: `� � l�4� � / 5_ <br />R��vl�,inn: 7 �� � 1 Thu�sday, Odo4cr 0i, 7_014 <br />