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� BACKWATt� PREVENTIJN DEVICE �INAL <br />INSTALLATION CHECKLIST <br />Inslallation Company Name and Contact Info: C.�A ��1 A i'� �LL� S t"�- U�b_ � iS� � N(. <br />[?ate Backwaler Prevention device (BWD) was ins(alled. �/ �/S Date this form was completed:J� .��V <br />Instaliation Property Owner Name 2nd Contact Info: _--y�s��� n�htp,s <br />Prnperty Address: / �e�8 (,t` /tt�iLli i <br />Pre•Instailation Inspection Ghecklist: <br />All iterns must be checked 'Yes' in order fur a BVJD fo be consrdered ror insiaflation <br />Is Ihere a basement or I�vel of the house tiiai is al or near assumed se���er mzin elevation. �s ❑ No <br />Eue lhere (ixtures in the house locatr.d below the upstream sewer rnanhole r��n etevalion? ��'�es ❑ N <br />Is ihe side sa.ver currenlly UNPROTEC7ED from se�ver backups (does no( have a �WD iestalledl? L Yes �] No <br />Site inspection Checklisl: <br />Ai! ifems must be checked 'Yes' before incpection is cansidered complete <br />`.Nas side sewer N inspected fror� building ta se�ver main? es ❑ �o Cu�dilion: _ <br />Dees side sewvr have at least 1%siope from ihe building to sevrer main? j�'�s ❑ No D cribe: <br />Have all 6uilding sewer drain connections to the side sewer been identitied and located? Yes ] No <br />Have all properiy slorm drainage conneotions to the side sewer been idenli(md and located? � es ❑ No, <br />Has prcperty heen evaluated for drainage def ciencies wilh iindings communicaled ;o pro�erty owner'? (y�'��� !] No <br />Installation Detaiis: <br />14'hat tyoe and brand o( BIND +vas inslalled al Ihis sit {Clean Cneck WV, Grinder pun�p, ,;tcJ: ��,�%�,',�� <br />VJhere v�as Ihn tlevice ins�alled (yeneral �oscnplio aUar,h iap)? iv� .LA-� �_SP�Gbi� <br />11�as Ihere a�y other sea�er or slorm drainage wnrk completed in conjundion �vith ihe B4V vaork? Is so please descnbe: _ <br />Installation Checklist: , <br />A« � all dovrnsoouts ard site drain3g� disconnecled Irom upstrearn af�I�he �BVJD? . es (1�No Commenls: ��_�`_ <br />Uocs �WD posi(ioning mcels m�nimum :�ope requiremen( of >1 "/o? �"1'es (_J No Commenls: <br />Can BN�D be pitlled oul tor inspection arid maintenance after loosening lhumb screw? fes (_� Nn <br />Is HWD iocked into Ihe pro � osition and Ihu b screw tighfened? (� ❑ No <br />C'rcle the 81N� co��er: irrigation cove landscape area � traHic load b aring r,over (dnve sur�ace) / access hatch (building) <br />!4'a� properly o��mer snown the location nf the insta ed BWD? 'es ❑ No Commenis: <br />P�operty Owner's Signaturc: ' �" - � Ualc: �Za �� <br />—�------- �--- --- <br />In;tallr.r's Signalure: _ � ��^ � Gt �— Dale: � Z 3�/j <br />Pevisinn:? 1 h�nnday,5eptemberli,JG14 <br />