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�ACKW�TER PREVENTIC)N DEVECE FINAL <br />INSTALLATIQN rHECKLiS'i <br />Installation Company Name antl Coniact Inio: � (�.s;:��' -� � <br />Date Backtvzter Prevenlion device (BWD) v:as installed: �- 1 S 1� Date this form was compleled:_ '—i ��� <br />Installation Prop�riy OvrnerName and Contact Infa PO��� �� � � <br />Prop�r�/ Address: ?-')'2"3 U ���,, i+� ��' <br />Pre-Installation Inspection Checklist: <br />/111 items mus[ be checked 'Yes'rn order (or a BlND to be considered forinstallaGon <br />Is ti•�ere a basement or level of the house Shat is at or near assumed sex�er main elevation? [� Yes ❑ No <br />Are there f�ures in the house locat2d belo���� the upstream se�ver manhole rim elevalionl [(] 1'es ❑ No <br />Is the slde sewer currently UNPROTECTED from sewer baskuos (does not have a BIND installed)1 []j Yes ❑ No <br />Site Inspection Checklisl� <br />All items musf be checked'Yes' 6e%re inspecfion is consideied complete <br />VJas side sewer N inspected from building lo seH�er main? �%] Yes ❑ No Condition: <br />�oes side se�ver have al least 1°b slope from the building to sewer main7 [�] l es ❑ No Describe: <br />Have all building se�ver drain conneclions to the side see+er been idenlifed and located? � Yes ❑ No <br />Have all property storm drainage conneclions to ihe side se��ier been ide�tiGed and Iocated? [�"Yes ❑ No <br />Has property been evaluated for drainage defciencies �vith fndings cammunicated to property oemer? �Yes ❑ No <br />Installation Detaiis: --., <br />lNhat typ� and brand of BWD �vas inslalled at lhis ile (Clean Ch_eckBuda/; �rinder pump, etcn.): <br />VVhere was the device installed (genera! description, atlach map)? —c ��� 5 ��Ji P cY1" ��_ <br />';'; as there any olher se�ver or storm drainage v�ork completetl in c�unclion vaith the 3UVD vrork? Is so pfease describe: _ <br />Installalion Checklist: � . <br />Are a!I dov,�nspouls and si(e drainage disc. ,aceted (rom upstream of the BWD7 � Yes ❑ �o Commenls: , <br />Does BVJD positiomng mees minimum slope requiremenl of >1%? [�] Yes ❑ No Comments: <br />Can BVdD be pulled out For inspeotion and maintenance afler loosening thumb screw? [�Yes ❑ No <br />Is Eil'JD locked inlo the ro,aer-�osifrorraidiittm�l�e�" ' hlened7 �] Yes ❑ No <br />Cirde the aWD co r: im�gation cever_(landsrape�a[ca)1Val�c-Idad bearing cover (drive suriace)1 access haich (building) <br />Was properiy o�nner show�n the localion of lhe inslalled l3bVD? �Yes ❑ No Commenis: <br />Prop^rty Ovaners Signature: � Da1e: <br />Inslallers Signature: _� Date: _�_'7='. � <br />Revisian: 2 - 1 Friday, September 12, 2014 <br />