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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> ��r►can �;�r� � � �� 5�-�L`�', � �c <br /> insiallation Company Name and Con�act Info:�� CC � p (�} �y):�y��5��� %i���, ��k:�ti,):�'�iD ��l��C� <br /> Date Backevate� Prevention device (BVJD)v,as installed: `t'T� Date ihis form v,as comp!eted� 4�/� <br /> Instailztion Property O�vner Name and Contacl Inio: ��j "� �7— �1('f� <br /> Properiy Address: �o�l� ���P Q�e0� •, (�l r� :!.x.� �,Q� O� <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yea'in order for a BW'D fo 6e consrde�ed for installation <br /> Is there a basement or level o(!he house that is at or near assumed sewer m2in elevation? �'es ❑ No <br /> Hre there fixtures in (he house Iocated belou-the upstream sewer manho!e rim elevation7�Yes ❑ No <br /> Is the side sev,�er currenlly UNPROTECTED from sewer backups (does not ha�� a B�VD installed)? [�'es ❑ No <br /> Site Inspection ChPcklist: <br /> .411 items must 6e checkeo'Yes'be(ore inspection is considered complete /� <br /> !':'as side se���erTV inspected from building to se��ver main7 [�'es ❑ No Condition:_l�S� <br /> Does side se�ver have at least 1%slope irom the building to setiver main? [�bYes ❑ No Describe: <br /> Have all building sewer drai�comections to the side se�ver been ideMified and located? [�]Nes ❑ No <br /> Have aV property storm drainage connections to the side se�ver been idenhfied and locatetl? �'es ❑ No <br /> Nas property been a��aluated for drainage deficiencics�vith�^:�ings communicated to prooerty owner? [�Yes ❑ No <br /> Installation Details: <br /> N1hat type and brand of BWD�.vas inslalled at this site(Clean Check BWV, Grinder pump,etcJ: _�Q�_�Q <br /> UVhere was ihe devi�e installed (general description, attach map)? �j�,P �,�2C�tiQ��S�x,{,�f'�. <br /> bl�as there any other sewer or storm drainage a�ork comp�eted in conjunction with ihe BWD work? Is so please describe: _ <br /> ---�-�n-� ---- <br /> Installation Checklist: <br /> Are ail do�vnspouts and site drainage disc.onnected frem upstream of the BbVD? [�'r.s ❑ No Comments <br /> Does BLND positioning meets minimum slope reyuirement of>1"/07 �Yes n No Comments_ <br /> Can B1ND be pulled out for inspeetion and maintenance aiter loosening thumb screv�? �-1'es ❑No <br /> Is BI�VD locked into Ihe pro eLposilion and ihumb scre�v tightened? �'es ❑ No <br /> Cirde the BIND cov : irrigalion cover(�dscape area)I traffic load bearing cover(drive surface)1 access hatch(building) <br /> VUas property owner shovm «�� localion of lhe installed BVUD?�Yes ❑ PJo Comments: <br /> Property Owner's 5ignature� /� Dale: .�-� f 5 <br /> Installer's Signature: � Date: �.____ <br /> Revision:2 1 Frida��,September 12, 201�i <br />