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��CKV�A�'�� P��V'�NTi�� �EVI�E F�NAL. <br />�NSTAL,��TI�� C�E��LIST <br />$��'�"� ������ <br />.� <br />� <br />�,ti 7 .� .r�.� .Y'�.�f'' 0�' ' ;T y , %' ) " - �' <br />Installation Campany Name and Contact info��% .�• ��. <br />, Date this form was completed: ��- f <br />Date Backw�ter Prevent�on device (BNlD) was install�d- �' ; � � _ �, f, � +� -, � �� ti .� ��� <br />Installation F'roperty Owner Name �a,�nd Contact Info: <br />Property Address: <br />�1 <br />Pre-1n��altation lnspecqian Checklist: <br />A(I items mctst be checked 'Yes' in order far a BWD to be �assu�med sewer fmar�n,e{eVation? �'e5 ❑ No <br />Is there a basement or ievel of the house thai is at or near a <br />Are there fixtures in the house located below the upstream sewer manhole, rim elevation? �'Yes ❑�10 <br />[ <br />s the side sewer currentiy UNPROT�CTED from sewer �ackups (does not have a BUUD installed)? �'Ves ❑ N° <br />�iie Ins�ection Chec{ciisf: <br />A!1 r'tems musi be checked `Yes' hef°r� ►nspectian is cansrdered complete <br />Was side sewer TV inspected from buiEding to sewer main? [�'eS ❑�� Condi#ion: "� <br />� es ❑ No Describe: <br />Does side sewer have at least 1°/o slape �ram fhe building to sewer main .�' <br />Have alf building sewer drain connectiflns to fhe side sewer been ide�tified and located? �eSYes� ❑ No <br />Have al4 prapeny storm drainage connections to the side sewer been Edentified and located � <br />s ro er� been evaluated for drainage deficisncies with findings carnmunicated tn proper�y oW���7 � YEs Q�0 <br />Ha p p Y <br />lnsxa(fatlan Details; ) , ;� " <br />What type and brand of BWD was installed af #his site (Clean Check BWV, Grind�r pump, etc• � _. t <br />� �'.. � .� (�,� t�. `C <br />Where was the device installed (general description, a�tach map) .�...c .C- <br />��las there any other sewer or storm drainage work compfe�ed ►n canjunction with the BWI3 work? Is so piease describe: � <br />��f , s� <br />Install�tinn Checklis�: � �!� Comments: ____.�__� <br />Are all dawnspouts and site drainage disconnected frorn upstream of tlie BWD .�'�es ❑ <br />� � I ��1:�es [j No Comments: <br />Does BUVD positioning meets minimum s3om��n en'an e a#ter foosening thumb screw? X�s ❑ No <br />Can BWD be pulled out fior inspection and � <br />Is BWD locked into ihe praper position and thumb screw tightened? �iYes ❑�1a <br />,----.__-� <br />Circle the BWD co r: rrr�gation caver _ ndscape area) I tra#fic load bearing cover (drive suriace)1 access hatch (building <br />�--� gW . Yes ❑ Na Comments <br />Was properky owner shown the Iocation of the in � ��'` ; <br />��� � i ' ' <br />--....... _. <br />----- pate: <br />proper�y Owner's Signatur�: _ , C-. <br />,� Date: <br />installer's Signature: <br />� � Friday, September 12, 2014 <br />Revision: 2 . <br />