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i <br /> I <br /> I <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATIOIV CHECKLIST ; <br /> i <br /> �r�c«n ��/.+ � �� �r �� se���� �_�c : <br /> , < <• -�n. -C �, �,, ,):���n :�r���C. ! <br /> Installation Compsny Name and Con�act Inio:���e i� �L a..��� 4 �S�I�n' �' " � i <br /> Date Backwater Prevention device(Bl4'D)v+as instailed: �i���1/ �ate this form tivas comp!eted-'S I� � <br /> i <br /> Insfallation Properiy O�vner Name and Contaet Into:% f • ��a����- j <br /> Property Address: I ��� ��r-�C—�%�-•��N� D'J�� ! <br /> i <br /> Pre•Installatian Inspection Checklist: ' <br /> Alf i�ems must be checked'Yes'in order lor s B'ND to be considered for ins!allation ; <br /> i <br /> Is there a basement or level c`the house that is zt or near assumed sewer main elevaGon?[��'es ❑No ; <br /> Are there fixtures in the house located belo�v the upsiream se�ver manhole rim elevation?�Yes ❑ No : <br /> is tne side sewer currenlly UNPROTECTED from sewer backups �does not have a Bl�UD i slailed)?�'Yes ❑ Uo � <br /> I <br /> Site Inspection Checklist: <br /> All ifems must be checked'Yes'be(ore inspection is considered comp!ete /'� � � <br /> Was side se,ver TV inspected irom building lo sewer main? �'es ❑ No Condition: _S�� <br /> � <br /> Does side ser�er have at least 1°/a slope from ihe builtling to sewer main? �Yes ❑iJo Describa: <br /> Have all building sewer drain connections to lhe side sewer been identifed and Iecated? �Yes ❑No ; <br /> Have ail property storm drainage conneclions lo the side sewer been identified and located? [�Yes ❑ No � <br /> Has property been evaluated(or drainage defciencies with findings communicated to property owner? �Yes ❑ No � <br /> ; <br /> Installation Details: j <br /> lNhat rype and brand oi BWD�vas installed zt this site�Clean Check BWV, Grinder pump,etc.): ���rr� ; <br /> lNhere was the device installed (general description,attach map)? �Y'I`/�'N��CIf"�T Q"r��-���� � <br /> Was Ihere any ether sewer or storm drainage�vork completed in conjunclion e+ith Ihe�NlD work? Is so please describe:_ i <br /> _ __ _ -�M O . <br /> ; <br /> Installation Checklist: i <br /> Are all downspouls and site drainage disconnected from upstream of the DVJD7 �Yes ❑No Commenls� i <br /> Daes BWD positioning meets minimum slope requirement of>1%? �,jYes ❑ �o Commenis:_ <br /> Can BWD be pulled out for inspection and maintenance aiter loosening fhumb scre�v? [�.]•Yes ❑ No i <br /> Is 8WD locked into the proper position and thumh scretiv tightened? �'Yes ❑No j <br /> 1 <br /> Circle lhe BWD eover igation cover(la scape area)I traftic load hearii.^cover(drive surface)!access hatch(bullding) i <br /> Was property o�vner shov!n the location of the�nstalled BWD? ,[ Yes �o Comments: • <br /> � � �.,_ J ., <br /> Property Ovmer's Signature:� _ � / Oate: �JT� <br /> Installer'sSignature: � __ Date: � � � j <br /> Revision:2 1 Friday,Sepiember 12, 2014 � <br /> j <br /> i <br />