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� BACKWATER 6'REVENTiON DEVICE FINAL <br /> ^�, INSTALLATION CHECKLIST <br /> � <br /> Inslallation Company Name and Contac, Info:�,i�'1 ��'S�LL�S �-V+1�i��(Z r �lv'C • <br /> � <br /> Da(e dackv�ater Prevenlion device (Blh'D)was installed: ___Da�e this form was completed. ' _. <br /> Inslalfation Property Ovmer Name and Contact Info: ��c�� �l�l��_� _ <br /> Property Address: /��l (�^��� <br /> Pre-Inst�illation Inspection Checklisi: <br /> All ilems musi b�checked 'Yes'in order lor a BWD fo be considered Ior installation <br /> Is there a hasement or le��el of lhe house thal is at or near assumed sev�er main eleva!ion? �Yes ❑ IJo <br /> Are Ihere 6xtures in the house localed below the upstream sewer manhole rim elevation? [�es ❑No <br /> Is Ihe side sev�er currenlly UNPROTECTED from sev�er backups (does nol have a �NlD installed)? �ZY'fes ❑ No <br /> 5ite Inspection Checkiist: <br /> /UI items must be checked 'Yes'befere inspection is considere�complefe <br /> VJas side sewer N inspscled irom :.uilding to se�ver main? �es ❑ No Condition:_ <br /> Uoes side se�ver have at least 1% slope from lhe building to sewer main? �Yes ❑ No Describe: _ <br /> Ha��e aL'building sawer drair connections to tne side sewer been identified and located? �es ❑ No i <br /> f lave all property storm drainage connections to ihe side sevrer been idenlified and localed? [�es ❑ No I <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? [l�a'cr ❑ No I <br /> f <br /> Installation Uetails: � <br /> What type and brand oi f3WD was installed at this sil Clean Check WV, Grinder pump,etc.): ____ ` <br /> Whem was fhr.device installed(yeneral description, aUach map)7 /� s�- r4-TTe���� ____ • <br /> � <br /> VVas there any other sewer or slorm drainaye work r,ompleted in conjunction with lhe BWQ v�ork? Is so please describe: ._ <br /> -- �— — ---- — <br /> Installation Checklist: � <br /> �ie�dl dovmspouls and site drainage disconnecled (rom upsiream oi lhe "UD? Yes L] No Commenls:_ <br /> Ooes BWD posilionmg mr.ets minimum slope requirement of >1%? Yes ❑ No Com enis: _ <br /> Can BWD be pulled oul(nr inspeclion and inaintenanr.e afler loosening lhum screw? Yes �] No � <br /> Is l3WD locked into Ihe proper posilion and thumb screw tightened? [ es �� No <br /> Grde the BIND cover: irrigation cover(landscape area)I tra(fic load be ring cover(drive surface)1 access halch (building) <br /> V,'as property o�vner shovm the location of lhe installr.d BWD? " es ❑ No Commen(s; ___!`�'�` <br /> /� � � �— I <br /> Property Ovrner's Sigriafure:__ L:•�� Q-��-�'�'� ___ Date: � � _ � .S___ � <br /> Insfaller's Signalure:_ �---- ___ Date: � - �z `�� _ � <br /> Hevision, 7 1 Uionday, September 15,2D14 � <br /> I <br />