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BACKWATER PREVENTION DEVICE FINAL <br /> �, INSTALLATION CHECKLIST <br /> f„��� �+C'�,��J, <br /> Instal!ationCompanyNameandContactlnfo: F C ;.�`�•-ilF�c_°�-�ir�r',`�:'c.�l`,!`, �L.C;/�G'%,7%'J�,'�� <br /> Date Back�rrater Preveniion device(BVJD)e�as inslalled:��_Date this form�t�as compleied: <br /> Installation Property Owner Name and Contaci In(o:�_ � "'F � �� �_��� <br /> a y.p � ,� /J / <br /> Property Address: � ` '�e�LcG.�'�]S�i-�___�—v��u=---���.Z — <br /> Pre•Installation Inspection Checklist: <br /> All items must he checked'Ves'in order(or a AWD to 6e considered for inslallation <br /> Is there a basement or level of the house ihat is at or near assumed sev�er main elevation?[�Yes ❑ No <br /> Are there fixtures in the house located beloe:the upsUeam sewer manhole rim elevalion?�Yes ❑ P�o <br /> Is the side se���er currently UNPROTECTED frcro se�ver backups(does not have a B�VD installed)?�"Yes ❑ �Vo <br /> Site Inspection Checklist: <br /> Ail items must he checked 'Yes'before irspection is considered complete <br /> Was side sevrer TV inspected from building to sewer main? � Yes ❑ No Condilion: __�Q(`fSr ___ <br /> ` <br /> Does side sewer have at least 1°6 slope trom the building to sewer main? [�Yes ❑ No Descnbe: <br /> Have all building sewer drain connections to the side se�•�er heen identified and located7 � Yes ❑�o <br /> Have all property storm drainage connections to the side seerer 6een identified and located? �Yes ❑ No <br /> Has properiy been evaluated for drainage deficiencies tvi�h fintlings communicated to property owner? �Yes ❑ No <br /> Installation Details: � <br /> VUhat rype and brand of BWD was installed at this sile(Clean Check BWV, Grinder pump, etc.): � <br /> lh'here v+as the device instal!ed (general descripiion,attach map)7 ���_�Q[p,��_�� <br /> �Nas ihere any ulher sewer or storm rainage tvork compl led in con�vncGon�•�ilh the aWD work?Is so please describe: _ <br /> -----���-'� ���?e�'�.��1_-- <br /> Installation Checklist: � <br /> Are all doe,nspouls and site drainage disconnected irom upstream of the BWD? �Yes ❑ No Commenfs <br /> Does BIND positioning meets minimum slope requirement of>1°o? �Yes ❑ No Comments_______ <br /> Can BWD be pulled oul(or inspeclion and mafntenance after loosening �humb scree+? �Yes ❑ No <br /> Is BWD locked inlo the pro EcpositiQn and thumb screw tightened? �Yes ❑ No <br /> Circle the BWD cov : irriyationfove �ndscape area)I tra(fic load beanng cover(drive surface)I access hatch (building) <br /> N�as property oe+ner shovrn Ihe localion of Ihe installed BWD'? (�J Yes ❑ No Commenls: <br /> Property O�vner'S Signatur : �� �'• ig 0"r '"' , Date: � — 3_ 1 fr _ <br /> Inslallers Signature:_ __ Dale: <br /> Revision:2 1 Friday,Septem6er 12, 2014 <br /> ' ( <br /> � <br />