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i <br /> BACKWATER PREVENTION DEVICE FINAL i <br /> INSTALLATION CHECI�CLIST ; <br /> ,�ni:r►c<<n �;��-,�. � s� se��, � �� � <br /> i <br /> Installation Company Name and Contact Info�S�CC ' P L '�,Z�✓+�1C95���i�'r!� �'k-L�'a����� , <br /> Date Backivaler Prevention device(BWD)was installed: `t�lS Date this form was comp!eted: �4/�0�/� � <br /> Installation Property Owner Name and Conlact In(o: _��/W �i t � � �) � � �7G1 —Ua�„ � <br /> ( - ,tI 1 <br /> PropertyAddress: 1 y.�� �7'P�FI'Lt�o .�fh_����/�� ���nl � <br /> Pre-Instaliation Inspection Checklist: <br /> AA ifems musf be checked'Ves'in order(or a BWD fo ba considered for instailafion i <br /> Is ihere 2 basement or level o(the house thaf is at or near assumed sewer main elevation? �Yes ❑ No � <br /> i <br /> Are Ihere fixlures in the house located below ihe upstream setver manhole rim elevation? � Yes ❑No <br /> Is Ihe side setver currently UNPROTECTED from sewer backups(does not have a BVJD installedJ? [y�"Yes ❑No i <br /> Sitc Inspection Checklist: � <br /> AU items must be checked 'Yes'before inspecfion is consrde�ed complete �+ � <br /> l��as side se�ver TV inspecled irom 6uildingdo sewer main? �Yes ❑ No Condition: l—�b7)� � <br /> Does side se�ver have al le2st 1%slope from the building to sewer main? �'Yes ❑ No Descrihe: ! <br /> Have all huilding setiver drain connections to the side see+er heen identifed and localed? [�Yes ❑No . <br /> Have ali propeity storm drainage connections to the side sev+er been identified and Iocaled7 �Yes ❑ No ' <br /> Has property been evalualed (er drainage deficiencies�vilh findings communicated to property owner? � Yes ❑No � <br /> � <br /> Installation Details: •. <br /> What type and brand oi B1�'D was inslalled at this site(Clean Check Bl4N, Grinder pump, etc.):��^_�� ; <br /> Where was ihe device ins(alled (general descnption,attach map)'? {�����(Jt����,�� i <br /> . � <br /> Was there any other see�er or storm drainage work completed in eonjunction wilh ihe�WD eaork?Is so please describe:_ ! <br /> i <br /> ----- -- — ----- -�� -------- ----- <br /> Installation Checklist: ; <br /> Are ali do��mspoufs and sitc drainage disconner.ted from upstream of the BVJ�? (�l'es ❑ No Commenls• � <br /> Does BN�D posi6oning meefs minimum slope requirement of>1%7 �Yes ❑ �Vo Comments _ ' <br /> Can BWD be pulled ou1 for inspection antl maintenance afler loosening thumb screw? [�!1'es ❑ No i <br /> Is BIND locked into the proper posilion and Ihumb scre�v tighlened? �Yes ❑No � <br /> Circle the I3WD cov . urigation cove�l dscape area)!iraffic load bearing cover(drive surface)I ac�:ess hatch(building) � <br /> Vdas property owner shown ihe ocation of th `15talled BWU? ��'es ❑ No Commenis:_ � <br /> � ,�1 � <br /> Properly Owner's Siynatu � �N Date: � / i <br /> Installer's Signalure: Date: _ �; <br /> - - � <br /> Revision:2 1 f'riday, September 12,2014 � <br />