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B,4CKWATER PREVENTION DEVICE FINAL <br />INSTALLATiOW CHECKLIST <br />Installation Company Name and Contzct Info: lo �/w.� :»�� 3� � lSo7 <br />Date Back�vater Prevention device (BWD) ti^:as installed:,�..'. ;��/�i �Date this fortn w�� �mpleted:��7/�-� <br />Installation Property OwnerName and Contaet Info:1 F,y S�._,iPs�!(� �`' 63�' 3� �� <br />Property Address: 3� �� iZ:�c n�/ <br />Pre-Installation Inspection Checklist: <br />All items must be ch �cked'Yes' in crder for a BVJD to 6e considered for instailah'on <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? (� Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? [�Yes ❑ No <br />is the side sevaer currenlly UNPROTECTED from se�ver backups (does not have a BWD installed)': �Yes ❑ No <br />Site Inspectlon Cheeklist: <br />AIf items must be checked'Yes' befare inspection rs considered compfete <br />Was side sewerN inspected from building to se�ver main7 �Yes ❑ No Condition: <br />Does side sewer have at leasl 196 slope from the building to sewer main? ,� Yes ❑ No Describe: <br />Have ail building sewer drain �onnections to the side se�ver been identiCed and localed? Q Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located7 � Yes ❑ No <br />Has property been evaluated for dtainage deficiencies tvith findings communicated to properiy owner7 � Yes ❑ No <br />installation Details: <br />1Nhat type and brand of BWD was installed at ihis si lea Che�k BV , Grinder pump, etc.): <br />1Nhere was the device installed (general description, aftach map)7 _r�o�> �varn � �� roua-ti s-1Je <br />i . i — <br />Was lhere any other sewer or slorm drainago work compleled in conjunclion wilh the BWD workl Is so please describe: _ <br />Installation Checklist: <br />Are all do�vnspouts and site drainage disconne�led from upslream of ihe BWD7 (�'Yes ❑ No Comments: <br />Does BWD positionin � meets minimum:iope requirementoi>t%? � Yes ❑ No Comments: <br />Can BWD be pulled ���t for inspdction and maintenance after loosening ihumb screw�7 �/] Yes ❑ No <br />Is BWD lochad into the proper positic�� and ihumb screw Gghtened7 � Yes ❑ No <br />Circle the BWD cover: ' gation co�r andscape area) �c load bearing cover (drive surface) f access hatch (building) <br />Was property owner shovm the lo ation of ti�in talled BWD? �]/ Yes ❑ No Comments:, <br />Property O�vner's <br />Installers Sianatu <br />Revision: 2 <br />\ /� .,.. Date: 3� 3/is' _ <br />--- Dale: 3iz�f, r� <br />friday, September 12, 2014 <br />