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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Instalialion Company Name and Contact Info: l�Y� P�1 l L) f'" t �nw� u�i '�� <br />i � <br />Date Bactitivater Preventio� device (BWD) was installed: � ��C� IS Date this form was crompleled: � <br />Installation Propedy Owner Name and Contacl Inio: I-',� e v� ��- 4� t- �(� �� � ���� I � <br />ProperiyAdd�ess: � `l � �r� C-�. � n � <br />Pre-InstallaHon Inspection Checklist: <br />Alf items must be checked'Yes' in order for a BWD to be considered for installation <br />Is there a basement or level of the house that is al or near assumed sewer main elevalion? [� Yes ❑ No <br />Are there fixtures in the house located belotv the upstream scwer m&nhole rim elevation7 � Yes ❑ No <br />Is the side sewer currently UPdPROTECTED irom sewer backups (does not have a BWD insfalled)? [�] Yee ❑ No <br />Site lnspectlon Checklist: <br />Afl items must be checked'Yes' before inspec6on is considered complete <br />Was side sE •rer N inspected from building to sewer main? � Yes ❑ No Conditlon: <br />Doas side sewer have at least 1% slope from lhe building to sewer main? �] Yes ❑ No Describe: ,� <br />Have all building sewer drain connections to the side sewer been Identified and located? (�] Yes ❑ No <br />Have all property storm drainage connections to the side sewer been Identified and located7 [� Yes ❑ No <br />Has property been evaluated for drainage deficiencies with fndings communicated to properfy avner7 � Yes ❑ No <br />Installatlon Details: � --�� <br />What lype and brand of BWD �vas installed at this sitle (Clean Check B Gnnder pump, etc.): <br />�- -- cQ�o ✓ ��iPC l� <br />Where was lhe device installed (general description, attach map� ��� - r�k. � rA �'^ <br />Was there a iy other se�,ver or storm drainage work completed in conjunction wilh the B4YD K�ork? Is so piease describe: _ <br />Installallon Checklist: <br />/�re all do�mspouts and sile drainage disconnected from upstream ol the BWD? ❑ Yes m No Commenis: <br />Does BWD posiiioning meets minimum slope requirement o1>i%7 [ZJ Yes ❑ No Comments: _�— <br />Can BWD be pulled out for inspec6on and maintenance ailer loosening lhumb scretiti? � Yes ❑ No <br />Is BWD locked into the proper posilion and thumb screv� tightened7 � Yes ❑ No <br />�— 7 ir�ffic load bearin cover drive sur(ace I access hatch (building) <br />Clrcle the BIND cover ��galion cov IaRUscap�) . g ( } <br />Was pmperty owner sTtown"II—ieloca on of the installed BWD? [t] Yes ❑ No Commenls: <br />'� / /i./ r <br />Property Owner's Signatu�e: ,3.,� - l�� � �'� Date: `�� ��/ � - <br />Instaliers Signature:,�/ �- Date: � ��___LS-- <br />( %� <br />Revision: 2 � 1 friday, Sep[ember 12, 2014 <br />