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� <br />� <br />BACKWATER PREVENTION DEVICE FIN4L <br />INSTA�LATION CHECKLIST <br />Inslallation Company Name and Confact Info: Yi c%\Cc,'� � M�I N ln LC_c': <br />Date Backwater Prevenlion device (BWD) was installed: �'/ �=�- �'S Date this form was completed:. Q' Z��S <br />Instaliation PropeAy Owner Name and Contact Inio: 2d SF � � S� - 3 r"Z •- �i Z 3 f <br />Property Address: 24o'Z- r`-ac; K� ��[� �vi rt„� c=_1r�,�•�c%t �'�- S'4� `u t <br />Pre•Installation Inspection Checklist: <br />All items must be checked 'Yes' in order �or a B WD to o= considered lor installa�'on <br />!s there a basement or level ot the house that is at or near assumed sewer main elevation? �Yes ❑ No <br />Are there fxtures in the house located belo�v the upstream sewer manhole rim eievation? I�Yes ❑ Ido <br />Is the side sewer curr?ntly UNPROTECTED from sewer backuFs (does not have a BWD installed)? (�Yes ❑ No <br />Site Inspection Checklist: <br />AI! items must be checked'Yes' be(ore inspection is considered complete <br />N�as side sev:er TV inspected irom 6uilding to se�ver main7 � Yes ❑ No Condition: ��Fn 1-� ��=--0 �. �.., �� �v <br />Does side sev�er have at least t°% slope irom the building to se�a�r main? � Yes ❑ �o Describe: <br />Have all building se�r�er drain connections to the side sewer been idenlified and located? [� Yes ❑ No <br />Have all property storm drainage connerfions to tne side sewe� been idenfified and located? � Yes ❑ No <br />Has properiy been evaluated for drainaae de iciencies �v�;h fndings communicaled lo property oerrerl [�Yes ❑ No <br />Installation Det�ils: <br />1Nhat type and brand oi 81ND �vas inslalled at this site (Clean Check BNN, Grnder pump, etc.) CLEh�.-� C(-Fe c�C <br />�Nhere was the device installed (general descrip ' n, attach map)? <br />V✓as there any other sewer or sform drainage �vork comoleted in conjunction with the BL4�D work? Is so pleas= des�ri6e: <br />Installation Checklist: <br />Are all dovmspouts and site drainage disconneeled from upstream of the B4VD? �Yes ❑ No Commenls: <br />Does BN'D positioning meets minimum siope requirement oi>1%7 �Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb s�rew? (�Yes ❑ No <br />Is BIND locked inlo Ihe proper position antl thumb scre�v lightened? � Yes ❑ No <br />Circle the 6WD cover. irrigation cover (landscape area) / traffc load bearing cover (drive surface� / access hatch (building) <br />N�as prope .ry o�mer sho�vn the location of the installed BWD? '� Yes ❑ No Comments: <br />i <br />Properiy Ovmer's Signature: �_.sct_. Date: y-�Y-/S <br />Installer's Signature:�.-. %� - Date: �'- 2�- �� <br />Revision: 2 1 Tuesday, Septem6er 16, 2014 <br />