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BACKWATER PREVENT�UN DEVICE FINAL <br /> � iNSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: M o�' l��U M h;i� �l a S - 76 D�- y T 6 U <br /> Date 3ack�valer Prevention device (B1ND)was insialled: I I -;�I-1�( Date this form was completed: I1-3�-i U <br /> Installation Property Owner Name antl Contact Info: �3M c e M�c C�`��=�n �/,;2 S :2 5�.� 5 7v y <br /> Properly Address: f L- I S �u,�h�� N Ne r���1 �--�A °1 S�„2 O 1 <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BV✓D to be considered for instaUation <br /> Is there a basemert or level of the house that is at or near assumed sevaer main elevation? (�Yes ❑ f lo <br /> Are there fixtures in the house locatetl below ihe upstream se,ver manhole rim elevalion? �Yes ❑ No <br /> Is the side sewer curren!ly UNPROTECTED irom sevder backups (does not have a BWD installed)?0 Yes ❑No <br /> Site InspPction Checklist: <br /> All ifems must 6e checked'Yes'be(ore inspection is considered complete <br /> Was side sc��er TV inspected from building to sewer main? �Yes ❑ No Condition: Gu=�- 5�°jze <br /> Does side sewer have at least 1%slope from the builtling to sev,rer main? �Yes ❑No Describe: <br /> Nave ali building sewer drain connections to ihe side sewer been identified and localed? %� Yes ❑ No <br /> Have all property storm drainage conneclions to the side sewer been identified and localed? �Yes ❑ No <br /> Has proper{y been evaluated for drainage defciencies vaith findings communicated to property owner? [k�Yes ❑ No <br /> installation Details: <br /> VJhat type and brand ot E3VJD t^ras installed al this site(Clean Check BWV, Grinder pump, etcJ: ��<� (��-�/� <br /> IWhere a�as the device installed (generzl description, ariach map)? ��.�-� (��� cr-���" �ti�� <br /> VJas there any other sewer or slorm drainage work completed in conjunction with the BWD�,vork?Is so please describe:_ <br /> _ N/� <br /> Installation Checklist: <br /> Are ali downspouls and site drainage disconnected from upstream o(the BWD? �Yes ❑ No Comments:_____ <br /> Does BWD pcsitioning meets minimum slope requirement of>1%? �Yes [� No Commenls: <br /> Can BWD be pulled oul for inspection and maintenance aiter loosening thumb screw? �Yes ❑ No <br /> Is BV��D locked inlo the proper position and thumb screw tightened? �Yes ❑ No <br /> Circle the BWD covec rrigation cove landscape area)I tra(fic load bearing cover(drive surface)I access hatch(building) <br /> Nlas property owner shovan the location of the installed BWD? �Yes ❑ No Commenls: <br /> Properly Owner's Signature: Date: <br /> Installer's Signature: ��� �� �'L�— Date:__!�� 5 U -/�{ <br /> lievision: 2 1 Monday,September 15, 2014 <br />