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�� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Instal!alion Company Name and Contacl Into: P�7�U..�l �-vL�C3!`� ��� <br />Date backwaler device (BWD) v�as inclalled: �3 ��� "�� �Dale this form v�as completetl: � <br />Installalion Property O�vner Name and Conlact <br />Property Address: <br />Pre•Inslallation Inspection Checklist: <br />All i!ems must be checked'Yes' in order �or a BWD fo be considered lor installa6'on <br />Is there a basement or level of lhe house lhat is at or near assumed seti^er main elevalion? [�Yes ❑ No <br />Are lhere 5xtures in ll�e house locatad beloer ihe upslream see�er manhole rim elevation?� Yes ❑ P:o <br />Is Ihe sioe se.ver currenpy UNPRO?ECTED (rom serier backvps (does not have a B4UD installed)? � Yes ❑ No <br />Site Inspection Checklist: <br />Hfl �tems must be r.hecked 'Yes' be(oie inspection is ronsidered complefe <br />N�as side se�.ver N inspected !rom building'o se�a�e main7 f� Yes ❑ No Condilion: _ <br />/ <br />Does side sev�er have at Ir.ast 1°o slope irem ;he building to sewer main? �Yes ❑ No Describe _ <br />Have all bwlding sev�er drain conneclions lo the sida sev�er been idenGfied and located7 �Yes ❑ No <br />Have all pro; arty storm drainage connections to the s�de se,ver been idenlified and located? �] Yes ❑ No <br />I las prcperty been evaivated for drainage de`�ciencies with fndi�gs communicated to property o:vner? � Yes ❑ No <br />!nstallationDetails: 1 �"� <br />l��hat rype and brand of BV�'D �vas inslalled at lhis site (Clean Check BWV, Grinder pump,. e/L�c,): �^Q� <br />IVl�ere �vas the device installed (gr,neral descriplion, aUach map)? ��j���,(J� 1'e���Q <br />--T " �— <br />`:Vas ih�re any olher sewer or s�orm drainage work compleled in con�unction �vilh lhe ABl4�D tivork7 Is su please describe <br />Installation Checklist: <br />Are a!I do:vnspouts and silr, drainage disconnecled hom upstream of the �Ih�D? �/j Yes ❑ ��o Comn�eNs _ <br />Does BNR' posi6oning meel utiinimum slope r^yuiremenl ot >t�a? �Yes ❑ No Commenls' _ <br />Can BIM� be pulled out for i��specliun and maintenance aRer loosening thumb scre�v? ❑ Yes [� Nc <br />Is Bl4N locked into Ihe proper position and thumb screv� tighlened7 �es ❑ No <br />C;rcle the �WV covec irrigali�n cover (lantlscape area) ! traffic load bearing cover (drive sur(acei / a�cess halcli (bu�!d�ng) <br />I�das homeov�ner sho�vn the local�o�oi thz installed A8WD7�J Yes ❑ No Comments <br />� <br />Properly O:�mer's Signature: _' �.� .�_ Date: �- I 7' Z U�� <br />Ins;aller's Signature: _ � .� � ��-� Date: � '�S <br />Revision: 2 <br />Thursday, OctobPr 02, 2C14 <br />