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f <br /> ; <br /> � BACKWATER PREVENTION DEVICE FINAL ; <br /> „ INSTALLATIVN CHECKLIST j <br /> I <br /> � 's 1 Ur.h; � ' L� I <br /> Inslallation Company Name and CoMzrt Info� { <br /> Date Back��rater Prevention device(B:ND)v+as installed: � 2c�1 Date this(orm+vas compteled:�� I <br /> Installat�on Property O:mer Name and Contact In(a � <br /> Propertykddress:_��_ �e. �y___,__�l�re }I <br /> Pre•Installation Inspection Checklist: <br /> All items must be cl�ecked'Yes'in order for a BDVD fo be considered lor instalfafion <br /> Is there a basement or level of the house that is at nr near assumed sev:er main elevation7 �j Yes ❑No <br /> /+re I7ere�ixtures in Ihe house localed below Ihe upslream sewzr manhole rim elevation?�Yes ❑No <br /> Is the side se�ver currenUy UNPRO i ECTED from sea�er bzckups(does not hace a BWD installed)? [�Yes ❑No <br /> Site Inspection Checklist: �f <br /> Al!ilems must be cheeked'Yes'be/�re inspec6cn is considered complefe � <br /> Was side sewer TV inspected Irom bwlding to sewzr main� [�Yes ❑No Condition: O�, 5���5cw.e <br /> Coes side sewer have al least 1°o slope irom Ihe building lo sewer main� �Ves ❑ Ido Describe. + <br /> Have all budding se�ver drain connec!rons lo the side se�eer been identified and localed? Qt Yes ❑ No <br /> �ave all property slonn drainage conneclrons to tlie side se�•�er been idenlifed and located9 [�Yes ❑No <br /> R3s pwperty been evalua(ed for drainage deficiencies c�ah tindings communicaled to property ot�mer? [�]Yes ❑No <br /> Irs;allalion Details: � <br /> Whal type and brand of BWD a�as installed al this site(Gean Check BV��V,Grinder pump,etc.): ��t�:, ��� �'-��- : <br /> +:Vhere v;as lhe device installed(general description, altach map)? iv. �,��r���a,�� j <br /> � <br /> �.Nas there any other sewer or storm drainage srork compleled in conjunclion ti�ith ihe BVJD vrork?Is so please describe._ � <br /> C�eulA�rJ �-�lcx�r_ •1«.... � <br /> Installation Checklist: ; <br /> Are all dovenspouts and sile drainage disconnected Irom upsiream o(the BWD7 �_yQ Yes ❑No Commenls:►.�c:5{c:w+� <br /> Dncs 8WD positioning meets minimum slope requiremenl of>I%� [�]Yes ❑No Commenis: <br /> Can BWD be pidletl out for inspeclion and maintenar�ce aher loosening Ihumb screvn p ves ❑No <br /> Is BWD locked into lhe proper position and thumb sc ew tighlened? �Yes ❑ No <br /> Circle Ihe 8WD cover: irrigalion cover(landscape area)!1raHic load�earing cover(drive suriace)i access hatch(building) � <br /> l�Vas property owner shoe+n the location o(ihe installed BWD? []tYes ❑No Commenis:_ •vs:i++uwF <br /> �- _ � i <br /> Property Owner's Si a � Dale: _ � � <br /> Inslaller's Signature ___ Dale: L� � <br /> I <br /> Nevision:2 1 Priday,Septembcr 12, 2014 I <br /> I <br />