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f <br />' BACKWATER PREVENTION DEVICE FINAL ! <br /> INSTALLATIOiV CHEC�LIST ; <br /> i <br /> i <br /> �►1E,�{�i car� �;� �� �r ��de �-�"t�l'r L �c� � <br /> Installalion Company� Name and CoNact Info7� C • C� . . ') ' ; -C�S� C�ir'rlc �r -):�����_/I�'_; ± <br /> Date Back�vaier Prevention device(Bb1�D)was installed:;���ale this form was completed:seiy� � <br /> / I <br /> Inslallation Properiy Ovmer Name and Contact Info:��� L�Y'.E� �1"�a rR--��x�_. i <br /> Properfy Address: 1—I I���ST�/�� "LS�an--1 I <br /> � <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BW(J to be considered for installation ' <br /> i <br /> is there a basement or level of the house that is at or near assumed sewer main elevation? [�Yes ❑ No ; <br /> Are there fixtures in Ihe house located bela�v the upstream sewer roanhoie nm elevalion? (�[Yes ❑ N� � <br /> Is the side sewer currently UNPROTECTED fmm sewer b2ckups(does no!nave a BIN�installed)?�Yes �] No i <br /> Site Inspection Checklist: � <br /> Ali items must be checked'Yes'be(ore inspec�ion is considered complete / ` <br /> Was sidz sewer TV inspecied irom building to sewer main? �Yes ❑ No Condilion:__L�- ; <br /> Does side sewer have at least 1%slope irom ihe building to sewer main? �Yes ❑No Describe: ; <br /> Have all building sewer drain connections to the sitle sewer been identified and located? �j Yes ❑No <br /> i <br /> Have all property storm drainage conneclions ro the side sewer been idenG(ied and located? �l'es ❑ No <br /> !` <br /> Nas property be2n evaluated for drainage deficiencies v+ilh findings communicaied to property osvne�? [�Yes ❑ No <br /> ; <br /> Installation Details: j <br /> What type and brand of BWD was installed at ihis site(Clean Check BWV, Grinder pump, etc.): � - - � <br /> Where was the devico instal!ed (general descripiion, attach map)7 ' � � 1� <br /> i <br /> Was ihere any other se�ver or storm drainage v+ork completed i�e/onjl�e�n wiih lhe BWD work? Is so please describe:_ ! <br /> i <br /> J�St[ V� <br /> Installation Checklist: � <br /> Are all downspouls antl sile drainage disconnected from upslream of the QIND? �Yes ❑ No Comments: ' <br /> Does BWU positioning meets rninimum slope requirement of>1%? �Yes ❑ No Commenis: � <br /> Can BWD be pulled out for inspection and maintenance aiter!oosening (humh screlv? �Yes ❑ No � <br /> Is AWD locked into the pro er osilion and Ihumb screv�tightened? �]Yes ❑ No i <br /> Gircle the BIND cov ' i aljQn rover(lar scape area)1 irafiic load bearing cover(drive surlace)I access hatch(building) � <br /> Was property o�,vner shasa�n ihe location (th�stalled BWD? �es ❑ No Commenls: ; <br /> � � <br /> Properiy Owner's Signature: Date: , �� f"^� � <br /> Installers Sigraiure:`___ <br /> ~ Date: � <br /> Revision:2 1 Friday,September 12, 2014 � <br /> f <br /> � <br />