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BACKW�TER PREVENTIOIV DEVICE FINAL <br /> INSTALLATION CFiECKLIST <br /> Installation Company Name and Contzct Info: ��'�I/o l�ir,�� .� <br /> Dat2 Bac6�vater Prevention device(81ND)eras inslalled: t7� ///�/�sD'ate this form���as completed: � �.s /3'� <br /> Insfallation Property O��rner Name and Contacl info: fC�G/ ���z ZS�-' 7 Zf�l� <br /> Prap?rty Address: �/G� /Zutik« Gve:�++ �sto/ <br /> , <br /> Pre-Installation Inspection Checklist: <br /> AI!items musf be checked'Yes'in order for a BWD to 6e considered for inslalla;ion <br /> Is there a basement or 12va10(ths ho�ss thal is at or near assumed sewer main elevation?[�Yes ❑ t�u <br /> Arc lhere iixtures in lhe house located below the upstream se�t�zr manhole rim elevation?�[]Yes ❑ ��o <br /> Is lhe sid=see�er currenily UNPROTECTED(rom se�vzr backups(does not h2ve a 61'�'D irst:lled)?��Y�� ❑ No <br /> Site In�pection Checklist: <br /> All items must 5e checked'Yes'be%ra inspeciion is considerad comp!e(e <br /> 1'�'as side szwer TV insp>cted trom buiiding to sevrer main'? �Yes ❑ No Condition: <br /> Does side se���er hati�e al lez:; i°�o s!ope 6om the building fo sev;er main? �Yss ❑No D�scriGe: <br /> Have all building se�ver drain connections to lhe sine sev�er be=_n identified and located? [/J Yes ❑No <br /> Ha��e all property storm drainage connections to the side sevrer been identified and located? J�Yes ❑No <br /> Has properfy been eaaluated for drainage desiciencies with tindings communica;ed to properiy ov�ner? �Yes ❑ No <br /> Installalion Details: <br /> Whal typa and brand of BWD was installed at this site , � Grinder pump, etc): <br /> ll'here�ti�as ihe devir.e inslalied(general descriplion,� , __�<+ck. ol �+�u sa un oc/ <br /> GGnf�«<, Gl t.io <br /> 1'Ja� there any other seerar or slorm tlrainage work completed in conjun�lion with the 6N'D v.o�i�?Is so please descrih?:_ <br /> Installation fhecklist: <br /> Are all downspouts and site drainage disconnecied irom upslream of the BI��D? �1'es ❑ No Commenls: <br /> Does BIND positioning meels minimum slope requiremant of>1%? �{�J Yes ❑ No Con:menis: <br /> Can 64VD be pulled out(or inspection antl maintenance�fter loosening thumb screw? �1'es ❑ No <br /> Is B1ND locked into the proper position and thumb scre�v tigh•,ened? �Yes ❑ No � <br /> Circle ihe BVdD cov •unq�tion cover(�fld5G3 fiic load bearing cover(drive sunace)/access halch(building) <br /> Was property owncr sho���n lhe location of the installed BWD? Yes ❑No Commenfs <br /> Propany0e+nersSi�nalure: � �� _ � Date: /�/���/.� <br /> Installers Signalur : - Date: //�`/�/,j' : <br /> Revision:2 1 Monday,September 15,2014 I I <br /> i <br /> � <br />