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BACKVli`ATER PI�EVEiViIOi� DEVlCE FtNAL <br />� iN�T�LLATI�fV �HECMCLiSi' <br />�,�,�--i ��,� � �� � � � � �.c�� ��� �'�'� L� 1..��- <br />lnstafiation Company �fame and Contact lnfo:�� ~ '� C; . `� � (' D' ' �- � �. ,, , � <br />Date Sackwafer Prevention device (BWD) was ins#alled: Date this form was completed: <br />Installation Property Owner Name and Contact 1nfo:�� �.n �C.i .�`-1-� ��`� �" � � `� �" `�� �- <br />- - �. ,-. � <br />Proper�y Address; <br />Pre-Installation Inspeciion Checkfis#: � <br />AI! items must be checked `Yes' in order far a BWD to be considered for instaUation <br />Is there a basement or Ievel of the house that is at or near assumetl sewer main elevation? �1'es ❑ No <br />Are there fixtures in the house located below the upstream sewer manhale rim e(eva�ion? �'es ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD instafled�? C[�les ❑ No <br />Site tnspection Checklist: <br />A1! items musi be checked `Yes' befare inspection is considered complete ,�-���� <br />Was side sewer i'V inspected from buiiding to sewer main? �es ❑ iVo Condition: �- <br />Does side sewer have at least 1% slope from the buiEding to sewer main? �es ❑ No Describe: <br />Have all buifding sewer drain connectfons to the side sewer been identified an loca#ed? �es ❑ No <br />Nave ali prope�ty storm drainage connections to the side sewer been identified and lacated.- es ❑ No <br />m icated to ro ert oWner? Yes ❑ No <br />Nas praperty been evaluated for drainage defic�enc�es wfth findings com un p P Y �` <br />Installation Details: p�� � <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): �f e��'- ^ <br />Where was ihe device installed (general description, attach map)? �� ��'� �� ��'� �� <br />Was there any other sewer or storm drainage work completed ir� conjunc�tion with the BWD work? ]s so please describe: _ <br />Installation Cfiecklist: <br />Are all tlawnspouts and site drainage discannected from upstream of the BWD? �es ❑ I�o Comments: <br />Does BWQ pasitioning meets minimum slope requirementof>1%? �es ❑ No Comments: <br />Can BWD be pulled out for inspection and mafntenance after loosening thumb screw? �es ❑ No <br />Is BWD locked into f r-posi�ion and thumb screw #ightened? �'es ❑ No <br />Circle the BWD co r: irrigation cov ~an pe area)1 traffic load bearing cover (drive surface)/ access hatch (building) <br />Was property owner shown the location of the installed BVIID2 �es ❑ No Comments: <br />Property Owner's Signature: � <br />Installer's Signature;�'"�D <br />Date: ��i�l �(� <br />Dafe: � � �` <br />Revision: 2 v�% / 1 Friday, September 12, 2014 <br />