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�ACKVIIATE� Pl�EVENTION L7EVICE FrNAL <br />INSTeALLATI�N �HECKL.�Si <br />�:{�-�i ��=�� �. ����� �� �° �� +.� ��-� �'�-.�"1 �. d�� <br />lnstallation Company Name antl Contaci )nfo:,�r �-� ��f; 4`:;7`'������,% �.�a Y1"�_ ���;��'�'�_�__� -_�"_�__.�� <br />Date Backwater Prevention device (BVIID) was installed: ol � Date this form was completed: ' <br />fnstallation Property Owner Name and Contact [nfo: ����`�,Q �i�'��G�r—�7�.�—"c� g� <br />Proper�y Address: �,�,�� � `-" l )� � �l � � l <br />Pre-Instalfafiion Inspection Checklist: <br />All iiems must be checked `Yes' r`n order far a BWD ta be considered for installafron <br />ls there a basemenf or level of the house tl�at is at or near assumetl sewer main eievation? � Yes ❑ No <br />Are there fixtures in the �ouse located below the upstream sewer manhole rim efevation? [�Yes ❑ No <br />Is the side sewer currenily UNPROjECTED from sewer backups (does not have a BWD instafled)? [�Yes ❑�lo <br />Si�e Inspection Checklist: <br />AI1 i%ms musf be checked `Yes' before inspecfion is considered complete <br />Was side sewer TV inspected from building to sewer main? � Yes ❑ No Cor�ditio�: ��YX.�- <br />Does side sewer have at least 1% slape from the bu�lding to sewer main? [�Yes ❑ No Describe: <br />Have all building sewer drain cannections to the side sewer been identifed and located? [c�Yes ❑ No <br />Have alf proper#y storm drainage connections to the side sewer been itlentified antl located? [�Yes ❑ No <br />Has proper�y been evaluated for drainage defiiciencies wifh findings communicated to property awner? � Yes ❑ Na <br />Instalfa#ion Details: <br />What type and brantl of 8WD was insfafletl at this site (Cfean Check BV1fV, Grinder pump, etc. : �� <br />Where was the device installed (general descripiion, attach map)? � <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: ____ <br />h�G��1 <br />lnstaliation Checklisf: <br />Are all downspouts and site drainage discannected from upsfream of the BWD? �Yes ❑ No Comments: <br />Does BVI1D posit�oning meets minimum s[ope requiremenf of>�%? �Yes ❑�!o Commer�ts: <br />Can BWD be pulled out #or ins�ection and maintenance after loosening thumb screw? � Yes ❑ No <br />is BWD focked into the pro�erposition and thumb screw tightened? � Yes ❑ No <br />Circle t[�e BWD cover: rrigation cov landscape area)/ tra�ic Ioad bearing cover (drive surface} 1 acc�ss hatch (building) <br />Was property awner sha `� ion of ihe installed BWQ? �Yes ❑ No Comments: <br />Property Owner's Signature: Y Date: ��� �/� <br />�.____" �_ � _ �� <br />Installar's Signature: Date: <br />Revision: z 1 Friday, September 12, 2014 <br />