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BACKWATER PREVENTION DEVICE FiNAL <br /> INSTALLATION CHECKLIST <br /> Installalion Company Name and Contact Infc:�l'7��5�'T� l5 ac�� `i�- �f�93 _ I <br /> Date, Baclnvater Prevention device(BWD)v:� ,installed:�—�I"��IS! Date this form v+as completed:3--L"a�/S` <br /> Installation Property O�vner Nam(�e and Contact Info:(.�i���4i� ��P�C� <br /> Property Address:,�1�/ I�OC��ell� �vf. �l J� l/�A . 9���/ <br /> Pre•I��stallation Inspection Checkrst: <br /> A!(ifems must be checked'Yes'in ord,r��r a BWD to 6e considered for instalfation <br /> Is there a basement or level oi ihe house thal is al or near assumed sewer main elevation?�Yes ❑ No <br /> Are there fixtures in the house located below the upsUeam sewer manhoie rim elevation7 �j Yes ❑No <br /> Is the side se�ver currenity UNPROTECTED from sewer backups (does not have a BWD inslalled)?�Yes ❑ No <br /> Site Inspection Checklist: <br /> Fl�I i�ems must be checked 'Yes'6sfore inspection is considered complete F`n � <br /> VVas side sewer TV inspecled from building to sewer main? �Yes ❑ No Condition: ��`�"�Y <br /> �oes side sewer have at least 1%slope from the building t6 sewer main? �7es ❑ No Describe: <br /> Have all building sewer drain conne�tions to ihe side se�,ver heen identified and located? �Yes ❑No � <br /> Have all ptbp�riy stofm drainage cc�nections to the side setver been identified and located? �Yes ❑No <br /> Has property been evaluated for d�ainage deficiencies n�ith findings communicated to property�o�vner? �Yes ❑ No <br /> Installation�etails: p�C���s� <br /> Vdhal type and hrand of BVt�D v�as inslalled at this sit (Clean Chec BNN,Grinder pump. .c.):�\ <br /> Where was ihe deviee installed(general description,attac map)? 1G1� �,(��� 1S /� <br /> Was ihere any other sew�r or slorm drainage�vork completed in conjunction with the BWD�vork? Is so please describe:6 <br /> Installation Checklist: <br /> Are all dovrnspouls and site dr�inaye disconnecled from upstream of the BWD? �1'es ❑No Comments: <br /> Does BWD posifioning meets minimum slope requiremeni oi>1%? �Yes ❑No Comments: <br /> Can BWD be pulietl out for inspection and maintenance aiter loosening thumb screw? �Yes ❑No <br /> Is BUJD locked inlo the proper positior� an rew tightened? �f Yes ❑ No <br /> Circle the BWD oover. irrigalion cove (landsr,ape are /treftic load beariny wver(drive sudace)/access hatch(building) <br /> 1Nas properly owner shcwn the locati\o ie inslalled BWD? �Yes ❑ No Comments: <br /> Property Owner's Signa�t,u,�\: ��--'� Date: � � � �`�-5 <br /> .IU���IY V`�i Date:3 '6'���� <br /> Installers Signature: IA <br /> Revisian:2 1 ivlonday,Septemher L,2014 <br />