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�ACKW�►�ER PREVENTION DEVICE FINAL <br />INSTAL.LA710iV CHECKLIST <br />Cc� �l <br />Installation Company Name and Contacl Inio:.�P 1. <br />Oate daclnvaler Prevention tlevice (BWD) was insta <br />Installation Property Ov+ner Name and Conlaci Info: <br />Property Address: <br />G <br />Date this form w.as <br />�L <br />Pre•Installation Inspection Checklist: <br />All items must be checked'Yes' in order for a BWD to 6e considered for installetion <br />Is there a basement or level of the house Ihat is at or rear assumed se�+�er main elevation? �'es ❑ No <br />Are there fixtures in the house located belo�v the upstream sewer manhoie rim elevation?�'es ❑ No <br />Is the side sewer currently U�PROTECTED from se�ver backups (does not have a BIND installed)? �+'es ❑ No <br />Site Inspection Checkiist: <br />All items must be checked 'Ves' before inspection is cansidered complete f <br />Was side sea�er 7V inspected from building to sewer main? �'es ❑ �o Condi'Jon: _� r� <br />Does side sevrer have at least 14o slope `rom the buiiding to sewer main? (y�'es ❑ No Describe: <br />! <br />Have ali building sewer drain connections to ihe side se���er heen identified and located? (��'1'es ❑ No <br />Have ail property storm drainage connecti�ns to ihe �ide sewer been identified and Iecated? [�es ❑ No <br />Has property been evaluated for drainage deficien�ies with findings communicated to proper�y owner? �-i'es ❑ No <br />Installation Details: � <br />What type and brand oi 8WD was installed at ihis site (Clean Check BWV, Grinder pump, etc.): <br />Where a�as the device inslalied (general description, attach map)? CN�P i',� �G �� ��-e� <br />Was ihere any other sewer or sbrm drainage v�or'K completed in � n��th the BWD work7 Is so please describe: _ <br />Installalion Checklist: <br />Are all downspouts and site drainage Jisconnected irom upstream of the B1ND?�Yes ❑ No Comments: <br />�oes BIHD positianing meets minimum slope requirement of>t%1 �es ❑ No Commanls: __ <br />Can BWD be pulled oul for inspeclion antl mainienance after loosening ihumb scre�v?,�Yes ❑ No <br />Is BWD locked inro the per-�osition and ihumb screw tightened? �Yes ❑ No <br />Circle lhe BWD cov irri �tion�eaer` I dscape area) I trafiic load beanng co��er (drive suriace) I access halch (buildmg) <br />Was property o�vner shoan (he locatian of lhe inslailed BWD? �'es ❑ �o Commenis: <br />Property Owmer's Sig <br />Installer s Signalure: <br />Revision: 2 <br />/ <br />Date: � � f J <br />J <br />Dale: <br />lay, September 12, 2014 <br />