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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Comoany Name and Contact Info: ��%��✓vN O�✓� 4� �-� -��� - U/ z? <br />Date Back�vater Prevenlion device (B�ND) �vas installed: I I I I•(�JLDaIe ihis form was completed: I(• 1 I 1� <br />Ins�allalion Property Owner Name and Contact Info: `i'Y� P S Q� ��'�-u �4 L72 <br />Property Address: !'�l�' �V C C.Y�.V i�'l� ��ve`f `j8L0� <br />Pre-Installation Inspection Checklist: <br />Afl ilems musf 6e checked 'Yes' in order lor a BWD to 6e considered for installatron <br />Is ihere a basement or level of the house Ihat is at or near assumed sev.�er main elevation? [}'lres ❑ No <br />Are there fixlures in the house Iocated below the upstream sev:er manhole rim elevation? [�'Yes ❑ No <br />Is Ihe side sevrer currenlly UNPROTECTED from sewer backups (does not have a B4l�D installed)? 1[�'es ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' be%re inspecfion is cansidered complete <br />Was si�e sewer N inspecled from building to sewer main? [�Yes ❑ No Condition: S o J�� P��- �� L�c"` <br />i — <br />Does side sewer have at least 7% slope irom the ouildirig to sewer main? es ❑ DJo Describe: <br />Have all `uilding sewer drain connections to the side sewer been identified and located? t�'�s ❑ No <br />Have all {uoperty storm drainage conneclions to the side sewer been identified and Iocated7 [�es ❑ No <br />Has property been evaluated (or drainage deficiendes with 6ndings communicaled to property owner? �'es ❑ No <br />Installation Delaiis: r <br />Whal type and brand o( BWD v�as installed at this site (Clean Check BWV, Grinder pump, ela): Lt,�-1 i'•4'IRL� �_ <br />Where was lhe device installed (general description, attach map)? �L=� b9-p • <br />Was ihere any olher sewer or slorm drainage wor'R completed in conjunclion wilh the BWD work? Is so please descnhe: <br />Installation Checklist: <br />Are all downspouts and sile drainage disconnecled from upstream ot ihe BWD? es ❑ No Commenls: <br />Does BWD positioniny rneets minimum slope requirement of >1%? 0� ❑ No Commenls: <br />Can BWD be pulled oul for inspeclion and mainlenance a(ter loosening Ihumb scre�v9 L�-1'es ❑ No <br />Is BW� locketl i�N ihe proper position and ihumb screw tightened? (7-Y� ❑ No <br />Circle the BWD cover. irrigation eover (landscape area) iraffc load bearin cover drive surface) I access hatch (building) <br />Was property o�vner shown the localion of IhE; installed BWD? �� ❑ No Commenls <br />-/r � C' J <br />PropeRy O�vner's Signat `c �= Date: i 1.11 • � S <br />installer's Signature: � Date: � 1•��� F�b <br />Revision: 2 1 Friday, September 17, 2014 <br />