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BACKWATER PREVENTION DEQ IE RNAL <br /> NSTALLATMN CHECKUST <br /> installation <br /> Company Name and Contact Info: <br /> Date Bachlater Prevention device(BiAq was installed: <br /> Date this form was completed: V/--1 <br /> Installation Property Owner Name and ConjactL <br /> -or <br /> Info: ZV f—c!71 2 <br /> Property Address: 7�LS <br /> Fire-ins atIe£i�n 1—C XI <br /> InsPection Checklist: <br /> All items must be checked'yes,in order for aS WD to be considered,or installation <br /> Is there a basement Or level 0'1:the house that is at Or near assumed sewer main elevation? Yes []No <br /> Are there FIXIfures in the house located below the upstream sewer manhole rim elevation?0,ye.3 ONo <br /> qo <br /> is the side sewer Cufrenfly UNPROTECTED from sewer backups(does not have a BWD insialled)? L�' <br /> SH&Inspecn chp Yes ❑ No <br /> All karns must be checked Yes'before insPecdOn Is considered complete <br /> Was-side sewer TV inspected from building to sewer main? <br /> wyes FlNo Condition. <br /> Does side sewer have at least I%slope from the building to sawar main? &Yes f-7lNo Describe:an <br /> Have all building sewer drain connections to the side sewer been id d located? N Yes E] No <br /> H2V0 all properL�storm drainage connections <br /> to the side sewer been identifi dentifed and located? ERYes No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? Yes L1 NO <br /> Installation Details: <br /> What type and brand Of BWD was installed at this site CCCe2j:Ch:eck <br /> , Grinder pump, etc.): le-, c- <br /> Where was the device Installed(general description, attach map)? OF <br /> Was there any other sewer or storm drainage work OrnpletLed in conjunction wiih the BIND work? Is so Please describe: <br /> S(V\{C ",— - . . <br /> Are all downspouts and site drainage dis <br /> connected from upstream of the,BWD? Zyes No Comments: <br /> Does BRAID Positioning meets minimum slope requirement or'>j%? ayes []No <br /> Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? gyes ❑ Na <br /> Is BWD locked into the proper position and thumb screw tightened? Zyes El No <br /> Circle the SVVD cove irrigation=Cover landscape area)/traffic load bearing cover(drive surface) access hatch(building) <br /> Was property owner shown the location of the installed BWD? ErYes ❑ No Comments: <br /> Property Owner's Signature: <br /> Date, <br /> Installer's Signature: <br /> Date: <br /> Revision:2 <br /> Monday,September 15,2014 <br />