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i <br /> , <br /> ; <br /> i <br /> BACKWATER PREVENTION DEVICE FINAL � <br /> INSTALLATION CHECKLIST � <br /> i <br /> � ���r� c«n �pe-�� ^r `�� �,� '�'J'� 4 LG � <br /> Installation Company Name and Confacl Info:S�r� R,�.��4.��,:�-��:5�,i n..i�)'J/)D :�)�!� <br /> Date Backv�2ter Prevention device(BWD)�vas installed:�D��j�[.J_Date this form was completed: a�-, — <br /> Installation Property Ovmer Name and Contact Info: ��,� A,-.,!�,/1 Y2�__.�•�4�5'e z- i <br /> Property Address: l9/9 /Zccc/c�x .W,� E-�z�rr wn- f S r�/ i <br /> Pre-Installation Inspection Checklist: i <br /> Al!items must 6e checked 'Yes'in ader for a BIND to be considered(or�nsfallatibn y <br /> Is there a basemenl or level of the house that is at or c�aar assumed sewer main elevalion? �'es ❑No f <br /> Are there fixlures in ihe house located belo�v Ihe upsiream sea�er manhole rim elevalion?�'Yes ❑No i <br /> I�rhe side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? �'es ❑ No � <br /> ,,ite Inspeclion Checklist: <br /> All items must be checked'Yes'6efore inspection is considered complete � <br /> Was side se�ver N inspected from building to sevler main7 [�es ❑ No Condi6on: � <br /> Does side sewer have at leasl 1%slope from the building to se�ver main? �JI'es ❑No Descnhe: <br /> Have all building sewer drain connections to the side sewer been identified and located? �1'es ❑No <br /> Have all properiy storm drainage conneclions to the side sewer been identified and located? � Yes ❑ No <br /> Has property been evalualed for drainage deficiencies�vith findings communicated to property oa�nen �bYes ❑No <br /> Installation Details: / , <br /> What type and brand o(Bl^!D�vas installed al lhis site(Clean Check BWV, Grinder pump,etc.): � � ` ( ull <br /> �Uhere was the device inslaUed(general description,aflach map)7 `��' ('D,�C3,1'.�'t-u=���-�S�l,{,.�I'� <br /> Nlas there any other sewer or storm drainage work completed in conjunclion with Ihe[3WD work?Is so please describe:_ <br /> ��aY►t� <br /> Instaliation Checklist: <br /> Are all do�vnspouts and site drainage disconnecled from upsiream of Ihe B�UD? `�Yes ❑ No Commenls: <br /> Dces 8WD posit�oning meets minimum slope requirement o(>i%? �Yes ❑No Comments: <br /> Can BWD be pulletl out for inspeclion and maintenance aiter loosening Ihumb screw? ,[�Yes ❑ No <br /> Is BWD locked i�to lhe proper-posilior��and ihumb screw tightened? �Yes ❑ No <br /> Circle the BWD cov r. irri aGent�er�I rldscape area)I traffic load bearing cover(drive surface)1 access hatch(building) <br /> Was property owner shown the loca6on of the instalied BWD? ��-Xes ❑ No Comments: <br /> Property Owner's Signalure: — pate: /� ��'I� <br /> Installers Signature: � �,c�.P Dato: �Ci c� ��S` <br /> Revision: 2. 1 friday,September 12, 2014 <br />