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� <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL � <br /> INSTALLATION CHECKLIST ' <br /> � <br /> � <br /> Inslallatian Company Name ard Conta�t Info: 4;, „ti{� {-f•�r� �i� L (�C � <br /> f <br /> Dste Qaclnvater Prevention dsvice(BWC)v�25 Insfalied_ �Date this (orm was compleied: ' <br /> Installalion Property Owner Name and Contact Info: I <br /> PropeRy Address: <br /> i <br /> Pre•Installatlon Inspection Checklist: ; <br /> All items mast be checked �Yes'in uder for a BWD to 5e considered(or installat�cn � <br /> Is there a bas=merl or level of the house ihal is at or near zssumed se�ver main etevation7� Yes �j �\'o i <br /> Are ihere fiztures in the hous=located below th=upstrezm sewer manhole rim elevation?�Yes ❑ No ' <br /> is fhe side sewer currentiy U�PROTECTEO irom sew�er backups(does not hzve a BWD inslalledJ? � Yes ❑ No j <br /> i <br /> Site Inspection Checklist: � <br /> AI!Rems must be checked 'Yes'be%re i�specfion is consrderad complete � <br /> Was side se�ver N inspzcted from building to sewer main7 �Yes ❑ No Co�dition i <br /> Do=s side sev;er have at least t',6 slope frcm the building to sev+er main? �1 Yes ❑No Describe: ! <br /> Haao all building sev�er drain connecllons to the side sewer been identi�ed and located? (�,Yes ❑ No � <br /> Have all property storm drainage conneefions to Ihe side sewer been identified and located? f�Yes ❑ No � <br /> i <br /> Has property heen evaivaled for drainage de�ciencies��:ith findings communicated to property owner? [/�.Yes ❑ No � <br /> f <br /> Installat(on Details: <br /> 11'hat type and brand oi 8WD was Instalfed ai this site(Cfean Check BtNV, Grinder pump,etc.): C1 ectv� C h P c-�C- � <br /> Where was the device mslailed (generaf description, att2ch map)7 ���i�.s hvv 5� ; <br /> VVas there any other se�ver or storm drainage�vork completed in conjunction wilh the BWD�vork? Is so ptease descnbe: ', <br /> . v�U — <br /> Installation Checklist: i <br /> Are all downspouls and site drainage disconnected Gom upstream of ihe BWD� �Yes ❑ No Commenls: f <br /> Daes 8WD positioning meets minimum slope requiremenl of>t%? �Yes ❑Na Commenis: ! <br /> Can BVJD be pulled out for inspection 2nd mainienance afier loosening thumb screw? �J,Yes ❑No <br /> Is B'ND locked info the proper position a �numb screw lightened? .�Yes ❑ No ' <br /> Circle Ihe BIND cover: irtigation cov r(landscap-�e /traNc load bearing cover(drive suriace)/access hatch(buitding) � <br /> Was property ov+ner shown Ihe localion of the installed BVJD7 �Yes ❑ No Commenis: � <br /> I <br /> � <br /> Property Owner's Signature:_ a �" ' ���te: � 7 /5� �I <br /> Inslaller's Signature:� ..F����t Date: Z j�"]'i�� ` <br /> ( <br /> Revision: 2 1 Friday, September 12, 2014 � <br /> I <br />