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� <br /> � <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL ` <br /> INSTALLATiON CHECKLIST <br /> I�stailation Compzny N2me and Contact Info: �1'a%,f=� P�k.^�i7�.�, �'�7 /k� � <br /> Date Bac'fi+ater Prevention device (BIh�D)v;as Installed: � 3 /-r Da;e ihis fortn was cempleted: ' �3��� ' <br /> Inslallalion Properfy Owner�ame and Cont�ct Info: u'�' NG.�c:�%�k � <br /> � <br /> Property Address: Z 3 �.Z t'�n e � <br /> Pre-Installation Inspectlon Checklist: � <br /> kfl items must 6e checl:ed'Yes'in order tor a BV✓D to 6e considered!a instal!ation : <br /> Is there a basement or level of fhe hous2 that is at or near assumed se�ver maia elevation?�Yes ❑�o <br /> Are t'nere fittures in the house located balow the upslream sewer manhole rim elevation?�,1 Yes ❑ No ; <br /> Is Ine side sexer cuRanUy U�PROTECTED`rom sewer backups(does not havz a BV��D installed)?i�Yes ❑No ; <br /> Site Inspection Checklist: � <br /> A;1 ifems must be checked'Yes'b�fore rnspection is consrdered complste <br /> 1h'as side sewer N inspec:ed(rom building to se�,�er main? �Yes ❑ �o Condition: � <br /> �oes side seeaer have at leasl 1%slope(rom the building to se�r�er main? �Yes ❑ No Describe: <br /> Have a:l buiiding sewer drain connections to the side sewer been idenlified and lo�.:ed1 [�Yes ❑No i <br /> have all propet�/storm drainagz connecGons to tne side seerer bee�'dentified and located? �Yes ❑No ' <br /> Has property been evaluated for drainage deficiencies�•rith 5ndings wmmunicated to properiy owner7 �Yes ❑ yo : <br /> . <br /> Installation Details: _.�_-- ; <br /> Vdhat type and brar,d of 61+�D�vas installed at lhi�a� Ciean Check B1lN, inder pump,etc.): <br /> lVhere�,vas the de��ice installed(general description,attach map)? � " ' '� '�" �i^�" o � ' <br /> 2 i�,rS� <br /> 1Nas lhere any other sewer or storm drainage v+ork completed in conjunction�ailh the BVdD work?Is so please describe: _ i <br /> Nc� <br /> Installaflon Checkllst ' <br /> Nra all dovrnspouls and site drainage disconnected irom uostream of the BWD9 �Yes ❑ No Comments: � <br /> Does B�ND positioning meels minimum slope requirement of>t%? �Yes ❑ho Commenix � <br /> Can BVdD be pulled out for inspection and mainienance after loosenirg thumb screv�? u]Yes ❑No , <br /> Is 84VD focked into the pro er osj(�pn and t screw Gghlened? �Yes ❑No `, <br /> Circle the BWD ver: irrigation crover(larttlsca�e ar'�Ltrifticfoad bearing cover(drive suriace)1 eccess hatch(building) I <br /> Was property o:ti�ner shovm ihe loca?ion of ths installed B4VD? �Yes ❑ No Comments: � <br /> / /� � <br /> Property O�vner's Signature• . � Da(e: 3�%j/ �� � <br /> Installers Signature- � •-- Date: 3/Z�I/.S' <br /> i <br /> Revision: 2 1 Friday,September 12, 2014 ! <br />