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, <br /> ; <br /> BACKWATER PREVENTION C�EVICE FINAL ' <br /> INSTALLATION CHECKLIST <br /> instalialion Comp2ny Nam�ard Contact Into:�l�•(./n f�Gr.tr�fji n�i , <br /> J <br /> Date Back�vater Prave�tion device(Bti1'D)was inslaHed: ; zS�iS Date this form�vas completed:�zs i-f � <br /> Installation Proper�y Ov;ner Name and Contact Inio:,�uun �rcc��� 1 t' <br /> Propzrty Address: 2 � 7 /2/-c�/fP� �� <br /> Pre-Instaliation InspecUon Checklist: <br /> A!!ifems must be checked'Yes'in order,`or a BWD fo 6e considered fo�irrstallation <br /> Is there a basement cr level of the house that is at or near assumed sewer main elevation?Q'j 1"es ❑No <br /> Are there 5xiures in the house loated belor�ihe upstream sewer manhole rim elevation?�{'Yes ❑No <br /> Is the sfde sev,er cu�ently UNPROTECTE�from se��rer backups (does not have a BI�VD installed)7,[/1 Yes ❑No <br /> Site Inspection Checklist; ; <br /> All items must be checked'Yes'6efere insp:cfion is consiaered complete <br /> 4'Jas side sewer P!inspected irom building to se�rer m2in? �jj Yes ❑ No Contlihon: <br /> Does si�e ser;er have at least 1%slope(rom lhe buildirg to sewer m�in7 [�j Yes ❑ No Descnbe: <br /> Have all building se�ver drain conneclions to the side sev;er bzen idenlifed and located? �Yes ❑No <br /> Hava atl property storm drainage connections to the side seerer been identified and located? [�Yes ❑ No <br /> / <br /> Has properiy been eealuated for drainage deficiencies wiln fndings communicated to property o�t�ner? �Yes ❑No <br /> Instaliation Details: <br /> lNhat rype and brand of 64'�'D was inslalled at this site�(��,Grinder pump,etc.):_ ,(,2"_ <br /> 4'Jhere e;as the device insta!led(general descripticn,altach map)7 �.��,��v�r n _- _ <br /> �Vas Ihere any olher se�ver or slor�n drainage erork completed in conjunction v,�ilh the BVJD�vork?Is so plr c.� �scribe:_ , <br /> ,.�/c� - - - <br /> InstallaHon Checklist: � <br /> Are all downspouts and sile drainage disconnecled from upstream o(the BVJD7�Yes ❑ No Ccmments: <br /> Does B�ND positioning meets minimum slop�requirement ot>t%?�Yes ❑ �o Commenis: : <br /> Czn�1h'D be pull�d out tor inspecfion and mainlerance afte;loosening thumb screer?�Yes ❑No � <br /> Is BL4'D locked into the proper position ar,d thumb scre�v Gghtened7 ,[�j Yes ❑No ; <br /> Circle the BLND cover�iaa ntio'cover�lands�a e j1 t�a(f;c load bearing cover(drive sur(aoe)1 access hatch(building) . <br /> --�__— <br /> UVas property ovrn>r shotivn lhe location of the installed BVJD? �]Yes ❑No CommeMs: <br /> � �--� , <br /> Property0vmer'sSignat� e/ur �%u"7/ Date: �-���� <br /> Installers Slgnatur� Da:e:��/�f <br /> —� <br /> Revision: 2 1 Friday,Sepiember 12,2014 <br />