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� <br />� <br />BACKWATER PREVENTION DEVICE FI6VAL <br />INSTALLATION CHECKLIST <br />�r}c.�.�� crcr� <br />iG <br />Installation Company Name and CoNact Inio:JNs F K� rc r�r•�r� �•�+-����•- •• �- �� <br />Date Backwater Prevention device (BN1D) v:as installed: �� � – Date this form �a�as completed:�1� �T— <br />Installation Propedy Owner Name and Conlact Info: �"�"^ i7� 'fi� <br />, . „ /J i. (� _ „G _ . � i0 ,� , ):�i1 i) $�' � �.-� C7� <br />Property Address: <br />Pre-Installation Inspection Checklist: <br />All items must be checked 'Ves' in order fa a 6WD to be considered for insfallation <br />Is lhere a basement or level of the house that is at or near assumed sewer main elevalion? Q�'Yes L I No <br />Are there fixtures in the house located below the upstream se�ver manhole rim elevation? 0 Yes ❑ No <br />Is lhe side se�rier currenfly Ui�PROTECTED from se�ver backups jdoes not have a BWD installed)? �Yes ❑ Vo <br />Site Inspection Checklist: <br />Afl items musf be checked 'Yes' before inspection is considered complete /� �,/ <br />VJas side sewer TV inspected irom building to se�r�er main? [�Yes ❑ No Condition� C�-�0�'(1 <br />Does side sewer have at least 1°'o slope from the building to sev�er main? (�Yes ❑ No Descrite: <br />Have all build�ng sewer drain connections to the side sewer heen identifed and located? C(�]'Yes ❑ No <br />Have ail propert� siorm drainage conneclions lo Ihe side sewer been identified and located? (�-Yes ❑ No <br />Has property been evaluated for drainage deficiencies ���ith findings communicaled to properiy o;vner? �Yes ❑ No <br />Instaliation Details: �P `�Z �"�� <br />What type and brand of B�ND �vas installed at ihis sile (Clean Check BWV, Grinder pump, etc.): C• i"� <br />Udhere eaas lhe devic;e installed (general description, altach map)? _�j � C% ��'C �ti`•' ��� ; I� <br />Was lhere any other se�ver or storm drainage w� I/eo�m`pLleled in conjunction wilh lhe BWD work7 Is so please descrbe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upsiream of the BWD? �Yes ❑ No Comments: <br />Does BWD positioning meels minimum slope requirement of>1°o? �Yes ❑ No Comments: _ <br />Can BWD be pulled out for inspection and maintenance aiter loosening thumh scre�v? �'es ❑ No <br />Is B1ND locked inlo the proper.position and thumb scre�v tightened? �Yes ❑ No <br />Circle ihe BbVD co r: irriqation co�.(fendscape area) I lraffic loatl bearing co��er (drive surface) I access hatch (building) <br />bVas property owner sho�vn lhe location of the installed BWD7 � Yes ❑ No Comments: <br />Property C <br />Installer's <br />Revivon: 2 <br />,� <br />Dale,� � " � �� 1 <br />Date: �� '-Z•�i —1 � _ <br />lay, September 12, 2014 <br />