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I <br /> i <br /> �ACKWATER PREVENTIOiV DEVICE FI[VAL I <br /> E„ INSTALLATION CHECKLIST � <br /> i <br /> �►�c;ri c�zn s�;(��-�� � ��de :Sc;L�, � �.c ; <br /> Instaliation Company Name and Contact Info�S��C� i�L' � � �"j„) `�-�*' `L�'5���1`�� � `��i� ��'`n '��r�� ' <br /> , / i <br /> Date 8ack�vater Prevention device (BWD)was installed:�(U�.(.�_Date this form was compleled:�(Cd.L_ , <br /> Installation Property O�vner Name and Confact In(o: �C-��'1 ) ��' 1� ��a� ` ��a� I <br /> Property Address:1�7� ��C�' �Q-��- � - �� �`��I � <br /> � <br /> Pre•Instaliation Inspection Checklist: ' <br /> All items must be checked 'Yes'in order�or a BIND to be conside�ed for insiallafion ; <br /> Is there a basement or level oi the house ihat is ai or near assumed sewer main elevalion? �Yes ❑ No ` <br /> Are there fixtures in lhe housc located 6elow the upstream sewer manhole rim elevation? [�'es ❑No � <br /> Is the side sewer cu«entty UNPRO i ECTED from sewer backups(does not have a 8WD instailed)?�'es ❑ No ' <br /> Site Inspection Checklist: <br /> All items must be checked 'Yes'be(ore insoection is considered complete ' <br /> Was side se�ver 7V inspPcted irom building to sewar main? �Yes ❑ No Condition:__C�(L}�� � <br /> Does side sewer have at leasl 1%slope from fhe building lo sewer main? �Yes ❑ No Describe: I <br /> Have ail building sewer drain connections to the side sewer been identi6ed and located? (�'I'es ❑ No <br /> Have all property storm drainage conneclions to the side sewer been idenlified and located? �t'es �] No � <br /> Has property been evalualed tor drainage deficiencies wilh 5ndings communicated lo property ovaner? [�'es ❑ No <br /> Installation Details: � <br /> What type and brand o(BWD was inslalled al lhis site(Clean Check BWV, Grinder pump, etc.):_�� i <br /> Where vaas lhe device inslalled (general descrip�ion,attaeh map)? .�� 1 � �U�S�—l��- ' <br /> Was there any other sewer or slorm drainage work completed in conjunclion with the E3WD work? Is so please describe:_ � <br /> -------��/.�°----- ! <br /> Installation Checklist� ; <br /> Are all dovmspouts aiid site drainage disconner,led from up:,iream of ihe CiWD? �Yes U No Commenls: : <br /> —( <br /> Does BWD posiliorung mecis minimum slapr,requirement of>1%7 �es l I No Comments:__ _._ __ , <br /> Can BWD be pulled out lor inspection and maintenaa�e after loosening thumb screw? �Yes ❑ No j <br /> Is I3WD locked into the pro>_r.yposition and ihumh screw lightened7 �-Yes ❑ No ; <br /> Cirale the HWD cove :irriyalion cover ndscape area) I lra(fic load bearing cover(drive surfar,e) 1 ar.cess hatch (builciing) <br /> V��as properry owner s io��n ��location oi ihe insialled BWD?�Yes ❑ No Comments._ , <br /> Property Otvner's Signaturcf:��lJ • ��� 14� Date: C�' / " ' " � <br /> Installer's Signature:._ -� _ c: ^ _ Dale� � � � � <br /> Hevision: 2 1 Priday, Seplcm6rr 17., 2014 . <br />