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� <br />� <br />BACKWATER PREVENTION DEVIC� FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: � <br />Date backwaler device (BWD) was inslalle� <br />Installation Property Owner Name and Contact Inio. <br />Property Address: ��-ff9 A ilf_�rr . <br />Date this form was <br />Pre-Instaliation Inspection Checklist: <br />Ail items must 6e checked'Yes' in order (or a B WD to be conside�ed lor instailafion <br />Is there a basemenl or level of lhe house thal is at or near assumed sewer main elevation� Yes ❑ No <br />Are there fxtures in Ihe house Iocated belo�v the upstream sev�er manhole rim elevation? Yes [� No <br />Is Ihe side se��ier currently UNPROTECTED from sewer backups (does not have a BWD installed)?� Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' be/ore inspection is considered cornpiele <br />INas side sewer N inspected irom building to sewer main? � Yes ❑ No Condilion: <br />Does side se�ver have at least 1%�:cpe from the building to sewer main7 �] Yes ❑ �.'� Describe: <br />Have all building se�ver drain conneclions to the side sewer been identified and localed? [� Yes ❑ No <br />Have all property storm drainage conneclions :� the side sewer been idenlified and localed? � Yes ❑ No <br />Has propert�; been evalualed (or drainage defciencies w�th findings communicated to propeAy o�vner? � Yes ❑ No <br />Installation Details: <br />What type and brand of BIND was installed at ihis site (Clean Check BWV, Grinder pump�, /e� c.): / <br />Where was t devi e install (general descrip ion, attach map ?� .L iJ/ �p� r l�Di.Sk <br />/n� . �� � ' <br />1Nas ther ' ny olher sew r or slorm drainage work com eled in conjunclion wilh Ihe ABWD work? Is so piease describe <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected irom upstream ot the BWD7 [� Yes ❑ No Commenls: <br />Does BWV pnsitioning meet minimum slope requiremenl of >1%? �Yes ❑ No Comments: <br />Can BW`� be puiled oul tor inspeclion and maintenance after loosening Ihumb screw7 �Yes ❑ No <br />is B1NV locked inlo ihe proper posilion and thumb screvr lightened? �Yes ❑ No <br />Circle the BNIV cover irrigation cover (landscape area)! traffic load beanng cover (drive suriace) / access hatch (building) <br />Was homeowner sho�vn the location of <br />Property Owner's Si� <br />Installer's Signature: <br />Revision: 2 <br />ABWD7 �Yes ❑ No Cammenis: <br />Date: �Pa Ls <br />Date: _ <br />Thursday, October02, 2014 <br />