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'- BACKWATER PREVENTION f�EVICE FINAL <br />� E�� INSTALLATION CHECKLIST <br />�� <br />Installal�on Cnmpany Name antl Cen;act Info� __�� ��� r� r1 i� S� 1'�t- li��'1 iS iiA�(� �� _ <br />i)�le Baekwater Prevention devic� (B'.ND) p.�as installed 3��� � Date this form vras completed: �•' 3 YO !s <br />�;:<_tallalion Properfy O��;ner �1'ame and Contact Inic _�Db�n� __�� --- <br />Properfy;�dd�r;=_<, 2� �3 � ov�v't� 'J�(' �,.�u�r�__i�s �Sl?1� f' <br />Pre-lrstallation Inspection Cheeklis!: <br />All �;cnu rnusf be cher.ked 'Yes' in order lor a BWD to be cons�dered /a instalfation <br />,s 'herc a basement or level c� Ine house3hal is at or near assumed se:ver main elevuiion'? j' !es �] No <br />i�,re Ihere fiztures in the house Iccaled below the upsiream ses�rer manhole rim elevation? � Yes ❑ Mo <br />, fh_� sjde sev�e� currenfly UNPROTECTED from se�a�er backup@ (does not have a 81^1C insr;;lledj? i;: Ye, � � t�c <br />Site Inspection Checkllst <br />AG;ie�rs mi�st he ch�cked `Yes' hefore rnspection is considered co lefe <br />':��as sidc serre� TV inspecled itom building to seiver main? Yes ❑ N�� /CpnCdlon� ___ __ <br />f)c�s side se:ver have at least 1% slope from Ihe building to sev�er m2in7 L� Yes ❑ No DP cribe: _. ___ ____ <br />iiave all building sewe� drain connections to the side sew�r oeen itlentified and located? Yes �[j No <br />I lave all property sform drainage connectionsto ihe sitie sev�er heen idenfifred and located? [fYes ❑ No <br />V1as prcper•,y Leen ��va'ua;ea (or drainaae defcie,ncies v:ith ilndings�communicated to property rn;�ner? � Yes []'�: <br />Installation Details: <br />;?�n�3t t��pa an;l i�rand of BWD was installed al fhis site (Clean Check BN��, Grinder pwnp, etc ) C%u� C'/�1� _ <br />':Vnere �'�as ihe d� v�ce mslallvd (yeneral descnption, �I�ar,h map)? ���.k__s�_iww_So __ �%or � s� �� <br />� / , �/� ��+ � -��--� � <br />. Q- �g i�-O �C' a� iMt1 �.:i�_._ '! �,�ry'�"u�cil.aL. r_ Ca'�' __/....5 .Y:"O�Ff <37'L/6� <br />T � <br />41�as lheie any other se�ti�er or slorm drainage wr.rk completed in conjunGicn �vith the �14�D �•�ork'? Is so plaase desr,r,Le /.��} <br />Installation Checklist: ��,/ <br />Are all �o�vnspoufs and site drainaye disconnecled fwm upslream o(the f3 �?[� Yes �] No Commen�s� ____ _ <br />Daes E3VJD posit!oning meets minimum slope re�juirement of >1%7 [ Yes ❑ No Cornpienls _.___ _ <br />/ <br />Can (31ND be pulled out for inspeclion and maintenance after Woseniny iha fiscrew7 [� Ycs ❑ No <br />I's BWD lor,ked inio the proper posdlon�and thumb screw tightened7 [�,�es ❑ No <br />Circle the BV1�D �ovei. <br />��� <br />-� .. .� -�., <br />\��las pro��erty ov+ner sho��m lhe localion qf h� installed HVJD� _ Yes �� No Comments: ___ ___________._ <br />�I'roperty ��wn�r's 5ignature, /�_ _ t`:' Date: __ _�-�=_t �____ <br />- T�-- <br />Install[ r a 5ignature: ✓��v _�� ����n'� Dale. _�i � 0� ls__ ___ __ <br />Revision:2�. � l Mnndiy; Sepiember t5, 7014 <br />