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E3ACK4VA7E� PREb'ENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Conlact In(o:. <br />Date Back�vater Prevention device (BbVD) vras <br />ll <br />��� <br />Date lhis form v+as completed: � �— <br />Installa6on Properfy Ow�er Name and Conlact Info: �✓-��� H{�i'�� � � 1�-G� ``'�' �� ��T��'^`'-�'' <br />Property Address: �`"� ��� ��-� � S� - <br />Pre-Installation InspecUon Checklist: <br />NII items must be checked'Yes' in order for a BWD to be consrder�d tor instalfation <br />Is there a basement or level of the house ihat is at or near assumed sewer main elevation? [� Yes ❑ �o <br />Are there fxtures in the house locaied belov+the upstream sewer manhole rim elevation? [�] Yes ❑ No <br />Is the side se�ver c��rrenily UNPROTECTED from sewer backups (does not have a BWD instalied)? (t] Yes ❑ No <br />Site Inspectior. Checklist: <br />All items must be chscked `Yes' 6efore inspectron is considered complefe <br />Was side sewer P' inspected from building to selver main? [7] Yes ❑ No Condition: <br />Does side sewer have at least 1°� slope from the building to se�ver m2in? �j Yes ❑ No Describe: <br />Have all building sevrer drain connections to the side sewer 6een identified and located? �] Yes ❑ No <br />Have all property storm drainage connections to the side se5ver been ldentified and located? � Yes ❑ No <br />Has property been evaluated for drainage defiaencies wilh findinos communicated to property ovrner? � Yes ❑ No <br />Instaliation Details: <br />What type and brand of 614�D was inslalletl at lhis sife Clean Chec WBk V�Grinder pump, etc.): <br />�Uhere �vas the device installed (general descnption, attach map)? �i (�-i � ��� � r� � ��� �� �'^ s L-' <br />Was there any other se�aer or storm drainage erork completed in cQnjunction with the BWD work? Is so please describe: __ <br />Installation Checklist: <br />Are all duvmspouts and site drainage tlisconnecfed from upstream of the 8WD7 � Yes ❑ No Commenls: <br />Does BWD positioning meeis minimum slop° requirement of >1%? � Yes ❑ �o Comments: <br />Can BWD be pulled out for inspection and maintenance afler loosening ihumb scree+? [%] Yes ❑ No <br />Is BWD locked inlo the prope�posi�ion and�iumtrscc �w tightened? � Yes ❑ No <br />Circle the BWD cover irrigation cover (landsca e area lraffic load bearing cover (drive surface) I access hatch (building) <br />NJas property ovmer shown the location of the inst�lled BWD1 �j Yes ❑ No Comments: <br />Property Owner s Signature: Date: <br />Installers Signature: �� / Date: � �� � � <br />� <br />Revision: 2 1 Friday, September 12, 2014 <br />