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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact In(o: <br />�..,�,/,,,ti/ `I <br />Date Backv�ater Prevention device (BWD) �vas installed: �"�' (� � Dale ihis form was completed: �' �"� S <br />Installation Property Ov;ner Name and Conlact Info: � <br />Property Address: S(o � U !Z � c���e If <br />-c6�-� 3�v C�31 �Ss� <br />A� <br />Pre•Installalion Inspection Che�klist: <br />FlII ifems must be checked 'Yes' in order for a QV✓D to be considered (or installafion <br />Is there a basement or levef o( the house that is at or near assumed ser�er main elevation? [� YFs C No <br />Are there fixtures in the house located belovr tl.z upstrea� se�ver manhole rim elevation? (i�l Yes ❑ No <br />Is the side se�+�er currently UIdPROTECTED from se�aer backups (does not have a BWD insialled�? � Yes ❑ No <br />Site Inspection Checklist; <br />All i(erns must be checked 'Yes' before inspection is considered complete <br />4Vas side sev�er TV inspected from building lo see;er main? OYes ❑ No Conditio�: <br />Does side sevrer have at least 1°�o slope from ihe building to se�ver main? [� Yes ❑ No Describ2: _ <br />Hava all buildiog sewer drain connections to the side see�er been identified and located? � Yes ❑ No <br />Have all property slorm drainage connections to the side see�er been identified �nd located? �k Yes ❑ No <br />Has property been evaluated for drainage de(iciencies ivith findings communicated to propert5� o�vner7 � Yes ❑ No <br />Installation Details: <br />VVhat type and brand o( BV��D was instalied at this site (Clean Check BWI�, Grinder pump, etc.): ��� <br />�Vhere was the device inslalled (general description, attach map)? `' ` � c� � � c-� _U.T j7�� tr-�.�" <br />1rJas Ihere any other sgwer or storm drainage tvork completed in conjunction e:i�h the BVJD vrork? Is so ple�se describe: _ <br />Installation Checkiist: <br />Are all dovmspouts and site drainage disconnected irom uostream of Ihe BWD7 �Yes ❑ No Commenis: <br />Does BIND positioning meets minimum slope requirement o(>1%? �Yes ❑ IJo Commenls: <br />Can BWD be pulled out for inspection and maintenance a(ter loosening Ihumb screw? [� Yes ❑ No <br />Is B1ND locked inlo ihe proper posilion and lhumb screvr tightenetl? �Yes ❑ No <br />Circle the B14'D cover: iirigation cover (lantlscape area) I tra(fic Ioad bearing co��er (drive suriace) ccess I�ate �uilding) <br />14�a; property o�vner sho:vn the location of the inslalled 81�VD? � Yes ❑ No Comments: <br />Property Owners Signalure: Dale: <br />Installer's 5ignature: ������- Dale: I-y- � S <br />Revision: 2 1 �vtonday, September 15. 2014 <br />