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I <br /> � <br /> BACKWAT�R PREVFNTI�UN DEVICF FIiV�►L <br /> iNSTALLf��'ION CHEC�(LtST <br /> .—, 1? <br /> Inslalla6on Company Name and G,ntact In(o: l.rv� b�t'�� — LI S� � 6 I � <br /> Date Back�vater Prevention devioe(BVJD)svas installed: 2 ZS—�`� Date this fonn was compieted; ._�-��-/� <br /> InslallaGon Property Owner Nsmo and Confact Info:��A-L'� 1 cvv-�'�C? <br /> Property Address: `,7�`�C� ��.�'1'� �� <br /> Pre-InstaHation Inspection Checklist: <br /> All items must 6e checked'Yes'in erder for a BWD to be considered(or inslaliation � � <br /> Is there a basement or level of the nouse that is at or near assumed se}ver main elevation? �'Yes ❑ No <br /> Are fhere fixtures in the house located belo�,v the upstream sewer manho!e rim elevafion?LKres, 0 No <br /> Is the side sev:e�currently UNPROTECTED from sewer backups (does not have a BVJD installed)? ,es ❑No <br /> Site Inspectior. Checklist: <br /> All items must be cherked`Yes'before inspection is considered complefe <br /> Was sida sewer TV inspe�ted from buiiding to sewer main? ' es ❑ No Condition: �U�✓L � -��� ' I <br /> ! <br /> Does side sewer have al least 1%slope Gom the building to sewer main7 [t�+'es ❑No Descnbe: i "L�k� �, <br /> Have all building sewer tlrain connections to lhe side sevrer been iden6fied and located? (�N�s ❑ No <br /> Have ail property storm drainage conne�tions to the side setver been ideniified and located7 �N�s ❑No <br /> Has p�operry been evaluated for drainage deficiencies wifh findings communicated te property owneR [�'� ❑ No <br /> Installation Details: ����e�� <br /> What type and brand of BWD was installed al this site(Clean Check BWV, Grinder purrNI,,,etc.): <br /> 4Vhere vras the device inslalled(general description,attach map)? �� bZ/rt�L' Y-�ea4 • — <br /> VJas ihere any other se���er or stortn drainage work co1 mpleted in conjunclion with the BWD work? is so please describe:_, <br /> �' �J (C1��A_ - <br /> Installation Che�klist: ,^ <br /> Are all downspouts and site drainage disconnec!ed irom upstream of lhc BWD? es ❑ No Commenls:�' I�UiI� <br /> ii Does BWD posilioninp meets miniroum slope requiremenl of>1%? es ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening ihumb scteen es �No <br /> Is 8WD locked into the proper position w tightenetl? es ❑No <br /> Circie the BWD cover. imgation cov (landscape 2rea ffic load bea �ng cover(drive suriace)/eccess hatch(building) <br /> Wasproperty owne�shown ihe loca6on o e installed BWD? es ❑No Comments: <br /> +'roperiy O�vne�s Signature� � Date: ✓ �LI 'I s <br /> installers Signature: . Date: �—��—�� <br /> Revlslon: 2 1 Frlday,September 12,2014 <br />