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� BA�KWATER PREVENTION DEVICE FIN�L <br />INSTALLATION CHECKLIST <br />i _ <br />� <br />Instaliztion Company Name and Contact In!o: �� i'�'\ �� �LL)S ��-1i�1� iS I�l!t� � C � <br />Dale Backwaler Prevention device (BWU) was installed: I-1 _ Dale this form �•aas completed: `/�/7/z,�1 �. <br />Inslallatior Prooerty Otvner Name and Contact Ir,fo: \a�t �' � S'�r. ��-5' Z.i 0- 7 o c{ p <br />Properly Address: '; Z5 Z� Qw k� S�>o <br />Pre•Installation Inspection Checklist: <br />Afl ifems musf be checked 'Yes' in crder lor a BtND !o be considered for irstallatior. �/ ' <br />Is there a baseme�t or level of the house that is at or near assumed sewer m2in elevation7, �� Yes ❑ No <br />Are there fixtures in the house located below Ehe upstream sewer manhole rim ele��ation? U Yes ❑ No <br />Is Ihe side sevier currently UNPROTECTED from sewer backups (does nol have a BWD inslailed)? Yas ❑ No <br />Site Inspection Checklist: <br />Aif �tems must be checked 'Yes' 6erore i.nspecfior is considered complete <br />�r,r�s side se�ver lU inspected irom building lo se�ver main? �es ❑ No Condi�ion: <br />Does side sewer have at teast 1"/o slope irom the building to sewer main7 ' Yes ❑ No Dc�scribe: <br />Have all builtling sewer drain connections to the side sewer been identified and located? �Yes [� No <br />Have all property storm drainage conneclions to the side se�ver been identified and located? �es ❑ No ' <br />Hes property been ev2luated for drainage deficiencies e�ifh f ndings communicated to property or;ner? Yes ❑ No <br />Installation Details: <br />V�'hat type ��nd brand of BI�VD �vas inslalled at ihis site (Clean Check BNN, Gnnder pump, eta): C_' ��N ((h_� c.(� <br />l�l'here ���as lhe device inslalled (general description, altar.h map)'? �� r- — SC eo�he,r o� <br />'In�.. t�. <br />�:'Vas there any othej setiver or storm drainaye work compleled in oonjunction �aith the BIND work� Is so please describe. !�Sc7 <br />I <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BVJD? • Yes ❑ No Comments: _ <br />Does oWD positianiny meets rninimum slope requiremenl of >t%? �"Yes ❑ No Co ments: _ <br />Can BN1D be pulled, out for inspedion and maintenance after loosening thumb scre�v? [�Yes ❑ No <br />Is B�VD locked into the proper position and ihumb screw ligMened'? [�es ❑ No <br />Circle fhe BW� cover: i�jp_all�or}�(I p�dsc�p�a) f iraflic load 4earing cover (drive surface)1 access halch (buiiding) <br />�Nas properly owner shost� the localion of ihe nsialled BWD? [/�Yes ❑ No Comments: <br />� ,� �� ��,��, , <br />Pr�ity"Oivner's Signatu�re t. � Dafe: i�` �%" � _ <br />i p �-�-- - <br />Installer's Signature: ��� �1' • � _ Dale: ! ' <br />Revision: ? I l Monday, September 15, ZOl+ <br />