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BACKWATER PREVENTION DEVICE FINAL <br />IIVSTALLATlOIV CHECKLIST <br />Installation Company Name and Contact Info: M u�-� I�<<n r� ��� +� y y�� 7�p —� 3� c <br />J <br />Date BackH�a(er Preven6on device {B�ND) was inslalieci: 3'r?—IT Date ihis iorm was completed: �—y�f� <br />Installafion Properly O�vner Name and Coniact Info: S�.r�- �, /`� c[ �✓r-�; c ot U 6 a 3y 5J'Z� <br />Property Adtlress: ��� v �zq ; h i!� ,�`t�e <br />Pre•Installation Inspection Checklist: <br />A!1 items must be cGecked'Yes' ir order for a BV✓D to be considered for insfaflation <br />Is there a basement or level nf the house that is at or near assumed sewer main elevation7 � Yes ❑ No <br />Are there iixfures in ihe house located 6elow ihe upstream sewer manhole rim elevation? �jYes ❑ No <br />Is fhe side sewer currently UNPROTECTED from sevier ba�kups (does not have a BWD installed)? �Yes ❑ No <br />Site Inspection Checklist: <br />All Bems must 6e checked'Yes' before inspection is considered compfete <br />1Nas slde se�ver N inspect?d from building to serJer main? � Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer mainl � Yes ❑ No Describe: <br />Have all building setiver drain connections to the side se�ver been identified and located? � Yes ❑ No <br />Have ail property starm drainage conne�tions to the sid� sewer been identified ar.d located7 �"4'es ❑ No <br />Has preperty been evaluated for drainage deficiencies wifh findings communicated to properiy owner7 j�Yes ❑ No' <br />Inetallation Detalis: <br />IA�hat type and brand oi �WD was insialied at this site (Clean Check BtNV, Grinder pump, etc.): �e� �cLc <br />1Nhe�e was the davice mstalled (general description, afrach map)? li✓� t� S��-C u� A�..�s.C.. <br />Was ihere any olher seweror storm dra fage work completed in conjunclfon wilh the BWD arork? Is so pleasa describe: _ <br />Installation Checklist: <br />Are all dotivnspouts and site tlrainage disconnected irom upstream of the BWD? �( Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%7 2[�(Yes ❑ No Comments: <br />Can BWD be pulied out for inspection and maintenar,ce after loosening thumb screw? � Yes ❑ No <br />Is BWD locked (nto the proper position and thumb screw lighfened? k] Yes ❑ �o <br />Circle the B�VD co r: irri ation cover ndscape area) I fraffic l�oa,�( bearing cover (drive surfaee) f access hatch (building) <br />Was property owner shown the loca6on of ihe installed BWD? pJ Yes ❑ No Commenl:: ___ <br />Propsrty O�a�ners Signature: Date: <br />(nstallersSignafure: , � - Date: 7`I�S'� <br />Rev�sion: 2 <br />Monday, Septemher 15, 2014 <br />