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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATIUN CHECKLIST <br />— ��r- �+C���1� <br />A.��ur�r„�-� ��.:1 c: `i-�7tC��'�Piil`:�� LC-L '-�C!�'�'���--���, <br />Installation Company Namea�id Contacl In(o:,-,�� —�--�- <br />Date Backwater Prevenlion device (BWD) was inslalled���_ Date this form was completed:—,j��,�--'t-'-'— <br />Installation Property Owner Name and Contact In(o: <br />Property Address: <br />Pre-Installation Inspection Checklist: <br />All items must be checked 'Yes' in orrle� for a BIND to be cons:demd for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? [� Yes ❑ No <br />Are ihere fixtures in ihe house located helow the upstream setiver manhoie rim eleva(ion? [�Yes ❑ No <br />Is lhe side se�ver currently UNPROTECTEO irem sewer backups (does not have a BWD installed)? [� Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' 6efore inspection is considered complete /� <br />Was side sewer N inspected fmm building lo sewer main? [� Yes ❑ No Condition. _( ��� _ <br />Ooes side sev�er have at least 1% slope trom the building to sewer main? [�.Yes ❑ No Describe: <br />Have all building sewer drain connec�ons to ihe side sewer been identified and located? [�Yes ❑ No <br />Have all property stomi drainage connections to the side sewer been identified and laated? (^�..Yes ❑ No <br />Has properfy been evaluated for drainage deficien�ies witti 6ndings communicaied to propery o�mer? [�Yes ❑ No <br />Installation Details: /� <br />What type and brand of BWD �vas installed at this site (Clean Check BWV, Grinder pump, ele.!: QPC�Y' �Pn��,Y <br />Where was the device instailed (general descriplion, attach map)? � f' (S_-P�C�CII't(�.� �S__Y�(d.L.�f" <br />Was lhere any other se�ver or storm drainage «�ork completed in conjunclion with the BWD work? Is so please describe: <br />InstallaUon ChecY.iist: <br />Are all downspouts and site drainage disconnected from upstream of the BVJD? [�'Yes ❑ No Comments: <br />Does BWD positioning meels minimum slope requirement oi>t%? [j� Yes ❑ No Comments: <br />Can BWD be pulled out for inspeclion and maintenance afler loosening thumb screw? �Yes ❑ No <br />Is BWD locked inlo tlie pro er o_, ositior <br />Circle ihe BWD cove . irrigaGon cover <br />Was property owner shovm the localic <br />Property Owner's Signalure: <br />Installers Signature: <br />Revision� 2 � <br />and ihum6 screw lightened? � Yes ❑ No <br />area) I haffic load beanng cover (drive surtace) I access hatch (building) <br />BN'0? (�J.Yes ❑ No Commenls: <br />oate: �� " f y — �/`� <br />oate: /Z— L«l —�/y <br />Friday, Septem6er 12, 2014 <br />