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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST. <br />Inslallation Company Name and Contact Info: <br />� <br />Dale �ack�vater Preventien device (E3V�iD) was inslalled: 'L - Il,- Dafe this form v+as completed: l <br />Installalion Property Owner Name and Contact Info:,�p�ti1 PAl1P��J -��� ' 2'S�" ` <br />Property Address: <br />Pre�lnstallation Inspection Checklist: <br />All dems must be checked 'Ves' in order for a f3WD to be considered for installation <br />Is there a basement or level of the house ihaf is al or near assumed sewer main elevation? [`�'�es ❑ No <br />Are Ihere fixiures in the house located below the upslream sev+er manhole rim elevalion? Q i'es ❑ No <br />Is lhe side sev+er currenlly UNPROT[CTED from se�ver bachups (does not have a BNlD installed)? es ❑ No <br />Site Inspection Checklist: <br />All ilams must be checked 'Yes' before inspection is considered complefe �� <br />VJas side sewer N inspected (rom building to sewer main? es ❑ No Condition: ��i �z� .. <br />Dnes side se���er ha��e al least 1% slope from the builtling to sewer main7 [�'1'�es ❑ No Describe: <br />Have all buildmg sewer drain conneclions to the side sewer been identified and located? [ es ❑ No <br />Have all property storm drainage connections to lhe side sewer been identified and located? C�'Yes ❑ No �' <br />Has properiy been evaluated for drainage deficiencies with findinys communicated ro property owner? �s ❑ No <br />a. <br />Installation Details: <br />1Nhat type and brand o( BWD �vas inslalled at this site (Clean Check E3WV, Grinder pump, elc.): �.� (%cF,� <br />Where �aas fhe device installed (general description, atlach map)'? V�'�P+�? �`�C_b�v� ��_ ,' <br />Was lhe�e any other se�ver or storm drainage tivork completed in conjunclion wilh the l3WD work? Is so please describe: ._ <br />--N-�' - <br />Installation Checklist: <br />Are all downspouls and site drainage disconn2cletl irom upslream oi the BWD'? ��s U No Comments: ___, <br />Daes 8WD positioning meels minimum slope �equirement o( >1"/0? [ es ❑ No 'Commenls: _ <br />Can RWD be pulled out for inspection and mainienance afler looseniny lhumb screw? Nf t'es ❑ �o <br />Is BWD locked into ihe proper position and lhumb screrr tighlened? es ❑ No ' <br />Circie Ihe B�A�D cover. irrigalion cove landscape area) rafiic Ioad bearing cover (drive sur(ace)1 access halch (�uiltling) <br />Nlas property owner shown the location of the inslalled B1ND? _ es ❑ No Comments: <br />Properly Owner's Signature _ �'� I G� __ Date: _� I�e 1 _ <br />---- — — — � <br />Installer's Signature:._ G� �ate: �� <br />Revision:'l. t. Monday, September 15, ZOl4 <br />> <br />�� <br />