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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> f►'►�r�cun �p �U � s� : e.���-� L LG <br /> InstallationCompanyNamean� Contactlnlo:T��1' ' � 4 ���44�Sfj��n-�iYY�li ''L' z�;��u;� <br /> Date Bacinvater Prevention de�ice(BWD)was installed:�l5 _Date this torm v�as completed:��_ <br /> Installation Property Owner Name and Conlact Into:( 'S"Y7� � ��P,.�.Y`_�����}��Z -_���4 <br /> Properfy Address: ��h I C' k P� �fV� • � r(, /� 0 ����� � <br /> Pre•Installation Inspection Ch¢cklist: <br /> Afl items must be checked'Yes'in order for a BWD fo 6e considered(or installation <br /> Is there a basement or level o(the house that is at or near assumed sewer main elevation?�Yes [_] No <br /> Are there fixtures in the house located helow Ihe upslream sewer manhole rim elevation? �Yes ❑No <br /> is the side sewer curtently UNPROTECTED from sewar bac'�ups(does not have a B�ND inslalled)?�[ Yes ❑No <br /> Site Inspectlon Checklist: <br /> Ali ifems must be checked'Yes'before inspection is considered complete <br /> Was side sewer N inspeded(rom building lo sewer main? �Yes ❑No Condition: ��1� _ ', <br /> Does side sewer have at least 1%slope irom the builtling l�sewer main? �j Yes ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? ��Yes ❑ No <br /> Have all property storm drainage connections to the side sewer been ideniified and Iocatetl? (�Yes ❑ No <br /> Has property been evaluated for drainage deficiencies v,�ith findings communicatetl to property owner? �J Yes ❑No <br /> Installation Details: ,/� � ; <br /> What typ°and brand of BWD was installed at ihis site(Clean Check BWV, Grinder pump,etc.):LSP.C"�I ��cc� E <br /> Where was ihe devicE installed (general description,atta�h map)? SF�_(',[ .f�ri(=���� Q.0 Vl�i.� (�{' � <br /> Was there any olher sevder or storm drainage�vork complelec:in conjunclion with lhe BWD�vork? Is so please describe:_ � <br /> ��� - � <br /> Ins!allation Checklist: " <br /> Are all downspouts and site drainage disconnected irom upslream of the f3VVD? (�Yes ❑No Commenls: <br /> Does 8WD positioning meefs minimum slope requirement oi>t%? ��Yes I 1 No Commenls: <br /> Can BIND he pal�a:l oul for inspeclion and maintenance afler loosening thumb screw7 �Yes ❑ No <br /> Is RiNC iocked into the prop�r{�osition and lhumb screw tightened? �Yes ❑ No � <br /> Circle the BWD co er.irrigalion coyer QeFldscape araa)I traffic load beanng ccver(drive surface)!access hatch (building) <br /> Was property owner shown the location of lhe installed BWD? �Yes ❑ No Commenls� <br /> Propery Owners SignaWre:Cl�l✓1-�����1)����W� Date:�/ � ` 1�� <br /> Installers Signature:___�/n Date:���� <br /> f� <br /> Revision:2 ] Friday,September 12, 7014 <br />