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; <br /> I <br /> I <br /> i <br /> 1 BACKWATER PREVENTION DEVICE FINAL I <br /> �' INSTALLATION CHECKLIST ; <br /> ; <br /> Installatio� Company Name and Contact Into`.J/,�1P� "-���-i'�.-- i <br /> Date backwater device(BWD)vras installed:I��—I�' ��' Date this furm was completed�� � <br /> Inslallation Property Oa�ner Name and Contact Info: i <br />� Prooerly Address: ,� 7 ✓f/' �}� ��, GV�2��!/' 11 �� � I <br /> Pre•Installation Inspection Checklist: � <br /> A!!items rnust be checked'Yes'in order lor a BV✓D to be considered for rnslallation � <br /> Is Ihere a basement or level of Ihe house thal is at or near assumed sev�er main e!evation?�Yes ❑ No i <br /> , <br /> Are there fixtures in the house localed below the upslream se�ver manhole rim elevation?�Yes ❑ No j <br /> 1 <br /> Is the side se�ver currenUy UNPROT[CTED from see�zr backups (does not have a BN�D installed)? Yes ❑ No ; <br /> Site Inspection Checklist: � � � <br /> Alt items musf be checked'Yes'be(ore inspection is considered compfete i <br /> Was side sewer N inspected trom building to se�uer main? �es ❑ No Condition ', <br /> Does side sewer ha��e al least 1%slope irc,m ihe building to sewer main? �es ❑ N�escribe: i <br /> Have all builtling sewer drain conneclions to lhe side sev�er been identified and located? Y ❑No � <br /> Have all property storm drainage connections io lhe side sewer been identified and localed?�Yes ❑ No � <br /> Has property been evaluated(or drainage defciencies e�ith i:�dings communicated lo property owner7 �Yes [� �o � <br /> Installation Details: � , // 1 <br /> What type and brand ot BWD was installed at this site (Clean Check BWV, Grinder pump, et�.): ,!� �_-r,�. � <br /> Where vr s tlie device instalied gencral descripli n, anach inap)? �,�'� ti � i <br /> � - i <br /> Wa there any other sewer o storm drainage work completed in conjunction wilh the AB4UD e�ork7 Is so please describe: ; <br /> � <br /> Installation Checklist: � <br /> Are all down:pouts and site drainage disconnecled(rom upstream of the IND? Yes ❑No Commenis: <br /> Does L�WV positioning meel minimum slope requiremenl of>1%? Yes ❑No Commenis: � <br /> Can 61h�'V be pulled oul for inspeclion and mainten�nr�after loosening umb s�re�v?�es ❑ No ; <br /> Is BNN locked i 'he proper position and lhumb screvt lightened�Yes ❑No � <br /> Circle ine 41NV cover. irrigation�o:�er(land�cape area)I tra(fic load bearing cover(drive surface)I access hatch (building) � <br /> 4Vas homeowner shown ihe location af the installed ABWD? [�es ❑ No Comments: j <br /> Property Owner's Signa !"'� �G� Date: �U� / ��/� f <br /> Installer's Signature: Date: �/S ! <br /> I <br /> i <br /> Revision Z � 7 Thursday,October 02, 2014 � <br /> � <br /> i <br />