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i i BACKWATER PREVENTION D�VICE FINAL � � � INSTALLATION CHEC�CLIST ' � � f. , Insiallation Ccmpany Nzme and Cont2ct Info:M�'`'� I '�-n�'"'� Yz S 7 C 0 �7C o � Date Back�vater Prevenlion device(B�VD):vas installed: �— I7— I�D�tortn was completed; ' � 7'I i Ins(allation Prcperiy Ovmer Name and Contact Info: ML4f�C.GI1 �e,�r�r �f2 r �S,�- � 7,25 � Property Address� _ � � U� �(I � S)' r,��f/ �„�j} �,�c�Y' I Pre•installation Inspection Checklist: '. All i(ems mus;ha checked 'Yes'in order for a 84VD to be considered for rnstaUation Is there a basement or level o(the hnuse khat is at or near assumed sewer main elevation?�Yes ❑ No i P,re there fxtures in the house located below the upsVeam sewer manhole rim elevation? �Yes ❑ No Is the side se�ti�er currenl!y UNPROTECTED from se�;er backups (d:,zs not have a BWC insfalled)?�Yes ❑ IJo � Site Inspection Che�Rlist: All ite,ms must be checked `Yes'be%re i�,spection is consloered complete ',4�as sde sewar N inspectec:from building to se�var main? �Yes ❑No Condition: w�2,�r I-�a.,,� Ulc ' Does s;de sevrer have af leasf 1%slope from the building to sewer main? �Yes ❑ No Describe: Have all building sewer drain conrecticns to the side sewer Ceen idenUfiad and Iccaied? �,J Yes ❑ �o , Nave aii prep�rty sFarm draiozge conneclions to fne side setiaer been itlenGfied and I�cated? �Yes ❑ No Has property been eva�ated for drainaae deficier�cies vnth findings communicated to prop:rfy oH�ner? �l Yes ❑ iJo Installation Details: ti":hat type and brand of BWD was installed at thi�site (Clean Check BWV,Grinder pump, etc.)� `1�� cr..�n/�, i tiNhere�vas the device inslalled(general dascription,attach map)? i n Ik-�c. r��- � --- 'i 4Vas there any other sewer or storm drainage work compieted in conjunction with the BWO�vork? Is so please descnCe: _ i ��,/.� i installalion Checklist: I Are a�i dovmspouls and site drainage disconnecled from upsiream o(the BWD? �Yes ❑ No Comm�nis: i Daes 8WD positionfng meets minimum slope requirement of>1%? ��Yes ❑ Na Comments � Can BWD be pulled out for inspec�on and maintenance a(ter loosening thurnb screw? ,�Yes ❑ No j Is B�VD locked into the proper posifion and thumb screw tightened? [�Yes ❑ No � +;irde fhe BVVD cove im atio r�landscapz area)!Uaftic load bearing cover(drive surface)!access hatch(building) Was property owner shown the location of Ihe installed BWD? �"Yes ❑ No Comments: Property Oti+�ners Signature: Date: _ _ 1 i Inslallers Sfgnature: �� Da,e: 2 r I 7—� S i Revision: 2 1 PAonday,September 15,2014