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i <br /> BACKWATER PRE:VENTION DEVICE FINA� <br /> INSTALLP.'TION CHECK�IST <br /> Installalion Company Nan�e and Conlat; Inlo' ���� � /� � 7� y� � — D/'7 "3 <br /> Date Backv�ater Provenhon dewce (BN'D)was installed�J�Z�C ate lhis form was completed (y z-��� 5 <br /> Instailalion Property O�tner Name and Conlact Info �6� `� `��� �O2 ( <br /> property A9dress �3 - � — <br /> Pre•Installatlon Inspection Checklist: <br /> All items must be chec6r,d 'Yes'in nrder lor a BlNO fo be considered lor msfallaUon <br /> Is lhere a t�semenl or level of the house that is at or near assumed se�ver main el��vation� .� es CJ No <br /> ArF there tiKtures in ihe house lor.ated below the upstream se�.ver manhole rim elevatinn���s [] No <br /> Is the side see+er curtently UIJPROTECTED from sewer t�ackups (does nol have a BWD installed)7 � rj No <br /> Site Inspection :hecklist: <br /> lill dems must be checked'Ves'be(ore inspecfion is consrdered complele 1 �� GI � <br /> / <br /> 1^!as side sewer N inspected fiom bwlding lo sewer ma�n �y'ves ❑No Condition <br /> Does side sawer have ai least 14o slope from Ihe building to sewer main7 �'fes ❑ No Desc e <br /> Have all building sewer drain coonections to the side sewer been identifed and Iccated7 [�}'fes ❑IJo <br /> Have all property slnrm drainage conneclions to Ihe side se�ver been identified and localed� QNeS �] P!o <br /> Has property been evaivated for drainage deticiencies with findings communicated lo property owner? [-i1� I � fJo <br /> Installation Details: / <br /> Whal rype and brand of BWD�vas instatled at this site(Clean Check B�W,Gnrinde�r pump, ctc): __ _GL-���L <br /> Where was the device instalied (general descnpUon, attach map)? .__ _�-�-e��—_--. .— <br /> Was Ihere any other sevrer or storm drainage v�ork r,ompleted in conjunction with Uie BWD e,ork�Is so please descrihe _ <br /> (I�L-�r-�C — <br /> Installation Checklist: <br /> Are all downspouts anA site dramage disconneded frorn upsiream of Ihe BWD? [�-}'i es ❑ No Comments <br /> Does BWD posd�oning meels rnirnmum siape requiremenl of>1°/a? [� [] No Commenls. _ <br /> Can BIND be pulled out for inspection and maintenance afler loosening Ihumh screw? In-�`ES (�I No <br /> Is BWD tocked into the proper posdion and thumb screv�tigh�ened� ��}X�s (_� No <br /> Cirr.le Ihe BWD cover irtigation cove pandscape area raffic load bearing cnver(drive suriace)I access hatch(�wld�ng) <br /> Was properfy owner sho�vn the lor.ation of Ihe installed BWD� ( � es [� Mo Commenis <br /> � A ��,,/ � <br /> Property Q�vner's Sig ure� Date. 1v O�' �.2 0 � � ' <br /> Inslaller's Signabue. A/ Date: Iv 9�'' 3 �-6� � <br /> Reviyion: 7 1 Friday,September 12, 2014 <br />