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� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installa�ion Company Name and Contact <br />.20�- �/G-� - y193 <br />Date Backwater Prevention device (BIh�D) �:�as in�talled: �I ��`�1� Date this form eras comple'e�: '% �'���5 <br />Insia!I�tion Propeny Owner Name ard Conlact Info: <br />Property� Address: <br />Rv, <br />Pre•I�stallation Inspection Checklist: <br />All items musf be r.her.ked 'Yes' ir order for a E�ND to be considered /or installa(ion <br />� ao� �/l�- 99y1 <br />Is t;�.e; e a basement or level of the house that is at or near assumed se�ver main elevatic�? 1�i Yes ❑ No <br />i+re inere fixtures in the house located belo�;� the upstream se�:�er manhc!e rim elevation? �J'j Yes (� No <br />Is ihe side ser�er currenlly UNPROTECTED irom se�ver backups (dces ncf have a BV�'D installed)7 � Yes ❑�do <br />Site Inspection Checklist: <br />All items must be checlred 'Yes' before insoection is c�nsioered complete <br />�r�rLs side sener TV inspected from building to se�^er main? � 1'es ❑ No Conditio�r. <br />Does side sevrer have at least i% slope from tf �e building to setver main? � Yes ❑ No Describe: <br />Haee all buildinc seeier tlrain cennections to the side se���er heen ident�fied and locatetl? � Yes ❑ No <br />Ha��a all prcperty storm drainaAe conn?ctions to Ihe side seerer been identi(ied and lo�ated7 � Yes ❑ No <br />Has property been evaluatetl tor drainage deficiencies v+itii findings communicated lo properiy o::�ner? � Yes ❑�do <br />Installation Oeiails: � I� <br />1'dhal typ2 and b and of BI�VD �,�as installed at this sit: �Clean Cno 'c BWV, Grinder pump, etcJ: ��.�1� <br />1��'here �:�as the dev;r.e installed (aeneral d2scription, atlach map)? �a�� . na 1S - �` "�' <br />1'das there aitiy other se�ver or storm drainage a�ork completed in conjunction �vilh the BN�D �vork? Is so please describe: <br />Installation Checklist: <br />Are all dovmspouls and site drainage disconnected irom upsUeam of ihe BIND? � Yes ❑ No Commenis: <br />Does Ci1�dD positioning mcets minimum slope requirement of >14b? � Yes �___) No Comments: <br />Can 81�'D be pulled out ior inspectiun and maintenance after looseniny Ihumb scree�? �j Yes ❑ No <br />Is BUJD locked into ihe proper position and lhurab screw tigMened? � Yes � No <br />Circle Ihe BWD cever: irrigafion cov r(landscape are ! traffic load beanng cover (drive sut�ace) / access hafch (budc'ing) <br />l�Vas propPriy owner shor�n the locatio �' s alled BUVD? � 1'es � No Coinments: _ <br />Froperty Ormer's Signat� re� `� ��te y y r'� —��(`y <br />InslzllAr's Signature: �``�11'V .c� Date: � � � �D/s <br />'C <br />{2e�•ision: ? <br />Monday, Septcmber 15, 201�1 <br />