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i <br /> BqCKWATER PREVENTION DEVICE FIfVAL � <br /> �. INSTALLATION CHECKLIST '; <br /> � <br /> i <br /> Installalion Company Name and Contact Info: �>•6,,>( f����<�r;.��� _ <br /> Date Backwaler PrevenUon device (QWD)was ;nstalled: I i�= �+�� Date ihis forn'� �vas completed �I � �.� ' <br /> 1 � <br /> Installation Propeny O��vner Name and Contacl In(o: I�� Il�l L 1'� I � � _ ' <br /> Properly Address � � � � ���-L Iw�� ��� � � <br /> i <br /> Pre•Installation Inspection Checklist: <br /> AO items must be checked 'Yes'in order for a BVJD b be considered(or installafio�r ' <br /> Is ihere a basemem �r level o'ihe house lhal is at or near assumed sewer main elevation?.��� Yes ❑ No i <br /> Are there f�xtures in ihe house loca(ed belo�v Ihe upstream se�.�er nianhole rim elevation��Yes ❑ No � <br /> Is the side se�ver�urrently UNPROTECTED irom se�ver backups (dees not have a BN!D instzlled)?'�] Yes [; No ; <br /> Site inspection Checklist: ; <br /> AH dems must be checked'Yes'belore insoection is cnnsidered complefe ! <br /> N�2s side se�ver TV inspected(rom building to se�:�er main? (�Yes ❑ No Condition: i <br /> i <br /> Does side seaier have at teast 1%slope from lhe buiiding b sewer main7 (�Yes ❑No Describe <br /> Have all building se�ti�er drain connectiuns to lhe side sewer been identified and located9 ]-Yes ❑ No <br /> � <br /> Have all property storm drainage connechons to Ihe side sewer been identifed and loca(ed? (�'�es ❑ No � <br /> Has prop>rty been evalualed for drainage deficiencies with iind�ngs communicated to property ov:ner? �] Yes ❑ No � <br /> Installation Details: � j <br /> l�Vhat type and brand of BN+D was installed al this sile (Clean Check BWV, Grinder pump,elc.): L �-�'l �i� L�2LLI-- j <br /> !Nhere was the device installed (general descripUon, aUach map)? (;"v�i:���� 11.<�?�1�� � <br /> ,�'�,c I <br /> 4Vas lhere any other sewer or storm drainage work completed in conjunction w�th the BN�D:vork? Is so please describe _ � <br /> h(; � <br /> Installation Cliecklist: �' <br /> Are all downspouls and sile drainaye disconnecfed from upslream of lhe E3Wp?�Yes ❑ No Commenis. i <br /> Does BWD positioning meets minimum slope requirement o� >t°o? .�Yes ❑ No Cammenls. � <br /> Can 84VD be pulled oul for inspection and maintenance afler �oosening thumb screw?`�"]Yes ❑ No I <br /> Is BWD locked into Ihe�[oper posihon and�humb screw lightened? �J'es ❑ No � <br /> Circle the BWD co��er.lrrigalion cover pandscape are�)I traffc�oad bearing cover(drive surface)I access hatch(building) i <br /> Was properly oa:ner sho�vn the location o e installed BWD?�1'es ❑ No Commenis _ <br /> � j <br /> / i <br /> Property Ovrner's Signature: 2«0�;�� �/� ' Dale: �.�,_��—__--- I <br /> � ,. � <br /> Installer's Signalure���,c�-� .����T�-�-�� Date. _� / :?- 7. / 7 <br /> �-- <br /> Revision: 2 ] Friday, September I7, 2014 i <br /> � <br /> I <br /> I <br />