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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> � <br /> Insla!lation Company Name and Contact In`o��..� 15 �I U��"J�•^�,�h�V� �-f-- <br /> Date Back�valer Prevenlion device(84VD)was installe���e Date th�s`orm�.vas compleled:�� <br /> Installation Property Owrer Name and Con;act In'o: C � 11rr�+ �6�'r�1��`(l'r�i <br /> Property Address: ��� �i /�1 �� �- lL � <br /> Pre•Instaliation Inspection Checklist: <br /> AU rtems must be checked 'Yes'in order lor a BWD to be considered fa ins;ailatron I <br /> Is there a 6as=menl cr level of the house that is at or near assumed sewer main e!evation?�{I Yes ❑ i:o ' <br /> Are there fixtures in ihe house located below the upstre2m seerer manhole rim e�evation? �Yes ❑ No <br /> Is the side sevrer currently UNPROTECTED from se�.:er backups(does nol have a B�:YD inslalied)7 ❑Yes ❑ Ko <br /> Site Inspection Checklist: <br /> A!I items must be checked 'Yes'be`ae inspectron is consider�d compk_te <br /> Was side set��er TV irspected trom budtlino to se�:er main7 �1'es ❑ No Condition OID eGc�n, Sr�+ fw�� <br /> Does side seerer have ot le2st i°o s'ope from the building to sewer main7 [j(1Yes ❑ PJo Descr�be: <br /> Have all buildir:g see�er drain connections to Ihe side se;ver been idenUfied ard located? �Yes ❑No I <br /> Have alt propert�storm drzinage connec;ions to the side se�.ser heen identifed and localed7 [�'�,'Yes ❑No ; <br /> Nas property been evalu2ted for drainage deficiencies e�ilh fir,dings communicated to proFerty ovmer? �1'es ❑ No � <br /> Installation Details: <br /> What type and brand of 84VD�vas iastallFd at this sile(Clean Check BWV, Grinde� pumo,etc.): <br /> VJhere tvas ihe device inst2l!ed (yeneral desuiption,2ttach map)? � 1��� C�+C� l` �' 1 <br /> Z���� "Py>CL_ O� `,��]�Y C+n �i'1L� Y�\C S<<� c� �.�n.� <br /> SNas lhere ary other se�,ver or slorm dra�nage v:ork completed in conjuncfon v.�th the BVJD vrork7 Is so please describe _ <br /> I <br /> Installation Checklist: � (� <br /> Arc all do�,�nspouts and site drainage disconr.e�tetl trom upstream of the BWD? �Yes ❑ No Comments�k`L <br /> Does B�ND positioning meels minimum slope requirement o(>i°i�? ��1'es ❑No Comments: _ �u0�� <br /> Can BN�D be pulled out for inspection and malntenance afler loosening ihumb screw? [Zf Yes ❑ vo <br /> Is BWD locked into ihe proper posilion and thumb scre�v tighiened? [�'es ❑No <br /> Circle lhe BVVD cover: irrigaUon cover(landscape area)!Iraffc load bearing cover(drive surface)I access halch(building) <br /> Was propeAy oemer sho�m the location ef the installed BWD? �es ❑ No Comments: <br /> Proper,y O�.vner's Signature: � �� Date: �- �m—i <br /> inslaller's Signalure: � � Dale: � <br /> Revision�2 1 Friday,September ]2,7014 <br /> I <br /> � <br />