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i <br /> ; <br /> ; <br /> BACKWATER PREVENTION DEVICE FINAL <br /> a INSTALLATION CHECKLIST � <br /> � <br /> i <br /> (�� . � �� � <br /> Inslallation Ccmpany Name and Contact Inio:. >/C� "- �-�L� �� ; <br /> Date back�vat=r device(BUJD) vias insialled � ���'� Date this form vras compleled �� � � ' . ���5 � <br /> Installali�n Proper�y O�vner Name and Contacl Info: G��1 ' i'�.�--�4vry ! <br /> �.�-�,,�,�` � <br /> Property Address --��=�� '-�`"', � �' `�.s F..1L�� �� _ <br /> Pre•installation Inspection Checklist: � <br /> All iferns must be checkeA'Yes'in order lor a BWD to 6e conside�ed lo�installafion � <br /> Is there a basement or level cf lhe house that is al or near assumed se��er main elevaDon7�Yes ❑No ' <br /> Are there fixtures in the house located bebw the upstream ser�er manhole rirn elevalicn?�'Yes ❑ No � <br /> Is the side sewer currently UNPROTECTED Irom see�er backups(does not have a B�ND inslalled)?��Yes ❑No <br /> Site Inspection Checklist: , � <br /> 1 <br /> AIf ifems must be checked'Ves'be/ore inspection is considered cornplete ` <br /> i <br /> Was side sevrer N inspe�ted from building to sewer main7 �Yes ❑ No Condition: <br /> Does side sewer haee at Ieast 1%slope irom �he building tc sev�er main? j� Yes ❑No Describe: E <br /> � <br /> Have all building sewer drain connec5ons lo ihe side setiver been idenhfied and focatea� �] Yes ❑ No f <br /> � <br /> Have all property storm drainzge conrecUons to lhe side sewer beon ideniified and Iecated? ,�]-Yes ❑No f <br /> Has property been avzluafed for draicage do6ciencies wdh fnd�nos communi�ated lo property ovmer� :�].Yes ❑ �b f <br /> Installation Details: -----"` "'"` <br /> l-Vnat lype and brand of BWD was inslalled�t4fiis site Clean Che �W, G ' der pump, etc.): _ _ � <br /> � t <br /> I��here v:as the device mstailed(general description, attach map)? _[�,..�L� , l5 . <br /> 1Nas there any other seti�ve}r qr storm dramage work wmpleled in conjunclion with lhe i\BWD rrak? Is so please descrihe <br /> til�k'� - -- [ <br /> Installation Checklist: ` <br /> Are all do�vnspouts and site drainaae disconnected irom upst�eam o(the l3WD?��]_Yes ❑ No Comments _ _ � <br /> Does 4WV posdioning meet minimum slope requiremenl of>t%? [�j\Yes ❑No Commenls _ i <br /> Can BWV be puL'ed cut for inspeclion and m�;�nance afler loosening thumb screw? �Yes ❑ No ; <br /> Is BWV locked into lhe proper position and thumb screv,tighlened7 �)Yes ❑No \ ; <br /> Circle lhe BV�N cover irrigation cover(landscape area)/traffic load hea�!ny cover(drive surface)I access hatd�(buildmg) � <br /> VJas homeo�vner shown Ihe localion o���Astalled A9'NQ? ,,,�'Yes ❑ No Comments: + <br /> Properiy 0�vner's Signature: !l.� -G-� Date: �•� � 7 J ?� � /� � <br /> / I <br /> Instalfer's Signalure: _ Date: � — � 7 �r'"���� ` <br /> Revision�2 Thursday, Octobcr 02, 2014 { <br /> � <br /> - I <br /> I <br />