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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />�r�/c«n �(� �G �r s��e se.�L�r, LLG <br />InstallationCompanyNameandContactin(oS Cr FC���,`�`j)`Zrr''_a._�__�'�tl1��i�'�"�"%� �'��t,�'NS- ��'�:� <br />Date Back�.vater PrevenGon device (BNJD) was installed:�� n�l.� Dafe ihis (orm ti�+as completed��� <br />Installation Property O�+ner Naine and Contact Info: �Q!Lt�F�` �t�t�l ��S -���-�i-�tt�--- <br />PropertyAddress:J,( I'__�_ �_____i l,` '�" '= � .�t ' <br />Pre-Instaliation Inspection Checklist: <br />llfl items must be checked 'Ves' in order for a BWD to be considen�d for ir sfall2tien <br />Is there a hasement or level cf ihe house that is at or near assume� sea�e� main ele:ation? �'es ( 1 PJo <br />Are there fixlures in ihe house loeatetl beln�v lhe upsiream sev+er manhole rim elevation? �-Yes [] No <br />Is the side sewer currenlly UNPROTECTED frcro sewer hackups (does not have a BbVD inslalled)?�'es ❑ iUo <br />Site Inspection Checklist: <br />r111 items musf be checked 'Yes' he%� inspection is considered complete � <br />Iti�as side seaver TV inspected fmm huilding to sevrer main? �Yes ❑ No Condition ��i�c{, <br />�oes side sea�er have al least 1"/o slope from the buildinn tn sewer main? �'es ❑ yo Describe: <br />Have all building sewer drai� conneclions to Uie side sewcr been identified and located? �=Yes ❑ No <br />Have all proper�� storm drainage connections to Ihe sitle _•_v�er been identibed ard located7 �=Yes ❑ No <br />Has prop2rty been evalu2ted for drainage deficiencies with findngs cemmu�icaled to properly ovarer? ,�Yes ❑ No <br />Installation Oetails: <br />What type and brand of BWD was instailed al this slte (Clean Check B�l�V, 6rinder pump, etc.). � <�D" l' � <br />�Viiere was the device installed (general description, atlach map)7 �� �� �/�,�'s'a��5-1J-S�G��� <br />1Nas there any olhur setiver or storm drainage work completed in conjuncCon wth the BWD work? Is so please describe: _ <br />--- -----��'_� -- <br />Installation ChecklisC <br />Are all dcwnspouis and sile drainage disconnecled trom a�slrea,n of the BWD? �Yes ❑ No Comments: __ ___ <br />Does BWD pesiioning meets minimum slope requirement of >19b? ��Yes �_ � �o Cammenls: _ __ <br />Can BWD be pulled out for insper.tion and maintenance aiter loosening lhumb scre+v? �-i'es ❑ No <br />Is OWD locked into ihe proper position and ihumb screw lightened7 �j'1'es ❑ No <br />Circle the BtiVD cover r�ngalinn co�-�landscape 2rea) I Iraff c Inztl bearing co�er (tlrive surface) ! access hatch (building) <br />L.._-'_�- <br />lh'as property o�vner shrn'm the IocaGon of ihe installed BWD�Yes ❑ No Commenls _ <br />Properfy Owner's Signature: <br />Inslaller s <br />-� Date: � /� -S <br />Date: � � �.5 <br />Revition: 1 <br />� 1 Friday, September ]2, 2014 <br />