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BACKWATER PREVENTION DEVICE FINAL <br />IiVSTALLATIOIV CHECKLIST <br />Cczn <br />installation Company Name and Contact Into:�1 �� !..'.0 � <br />Date Back�vater Prevenlion device (BWD) was installed� <br />Installation Property O�vner Name and Contact Info: _� <br />ProperiyAddress: !i��� ���^�n � ��� <br />G <br />�L <br />Dale this (orm was completed: ���� <br />... �n f � i l�n 4J� �,S'� � L77 <br />Pre-Installation Inspection Checklist: <br />Afl items must be checked 'Yes'rn order for a BWD to 6e considered (or instzllation <br />Is there a basement or level oi ihe house that is at or near assumed sewer main elevation? Yes ❑ No <br />Are there (ixtures in the h�• � Incated below the upstream sewer manhole iim elevation? Yes ❑ o <br />Is the side sewer currently l'NPROTECTEO from sewer backups {does not have a BIND installed)? Yes ❑ No <br />Site Inspection Checklist <br />Afl ifems must be checked 'Yes' before inspection is considere�omplete � <br />Was side sewer TV inspected trom building to sewer main7 Yes ❑ No/Condilion: (-�–�,,il f__ — <br />Does side sea:er have at Ieast 1% slope irom the building to se��ler main? � Yes ❑ No pescnbe: <br />--! <br />Have all building sewer drain conneclions to lhe side savrer been idenlified and located? lJ Ye� ❑ No <br />Have all property stonn drainage conneclions to the side see�e; been idenlified and located? [J Yes ❑�!o <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? d Yes ❑ No <br />Installation Details: <br />What type and brand oi BWD �vas installed at lhis sile (Clean Check 9WV, Grinder pump, etc.): , �� <br />bVhere was the device inslalled (general description, atlach map)? G� °� � <br />lNas there any other sev�er or storm drainage vrork completed iY cgn�ct� �vilh the BWD work? Is so please describe: <br />/ <br />Instaliation Checklist: <br />Are all downspouls and site drainage disconneeted from upsiream of tf}� DIND? Yes ❑ No Comments: <br />Does BWD posilioning meets minimum slope requiremenl af >1%? u�ies ❑ No omments: <br />Can BN�D be pulled out for inspeclion and maintenance after loosening t umb screw7 �v Yes ❑ No <br />Is BWD locked into the ce�erposition and ihumb screw tighlened? [�Yes ❑ No <br />Circle the BWD eov r. irriyalion cover (lands�ape area)1 traffie load�earing cover (drive surtace) I access hatch (hullding) <br />Was property owner shown the location of lhe inslalled BN�D? [Q Yes ❑ No Cornments: <br />� � <br />Properiy Otvner's Signature: <br />Installer s Signature: <br />Revision: � <br />Dale:1� f�s��DIS __ <br />Date: � –Z.Z —, �-r <br />Friday, September 12, 2014 <br />