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� <br />�� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: �"t1� , �' ��`°v "' <br />Date Baci�waler Prevention device (B4VD) �,�as installed: �' �— t 5- Date fhis form was completed: -� 4- 1S <br />Installation Property Owner Name and Confact Inio: o�V� 4A cx (1 <br />Properiy Address; <br />?re-installation Inspection Checklist: <br />All items must be checked'Yes' in order for a BWD to be considered for installation <br />Is there a 6asemenl or level of the house thal is at or near assumed serder main elevalion7 � Yes ❑ No <br />Are there fi�ures in the house looated beloe� the upslream se�ver manhole rim elevation? Q Yes ❑ No <br />Is the side seveer currently UNPROTECTE� irom s:e�er backups (does not have a BWD installed)7�j Yes ❑ No <br />Site Inspection Checklisi: <br />Af! items must be checked'Yes' before inspection is r.onsidered compfete <br />1'!as side sewer N inspecletl irom building to seiver main? �] Yes ❑ hb Condifion: _ <br />Does side sewer have at least 1"/a slope from the building lo sewer main? � Yes ❑ No Describe: <br />Have all building sevrer drain conneeilons ro the side seerer been Identified and loeated? [�Yes ❑ No <br />Have all properh, storm drainage connections lo the side se�ver been iden6fied and located? [7] Yes ❑ No <br />Has property been evaluated for drainaae deficiencies v+ith 6ndings eommunicatsd to properiy oedner? []�\'es �] IJo <br />Installation Details: � <br />V�'hat type and brand of BVJD �vas insfalied at ihis si (Ciean Check B, inder pump, etc.): _ <br />VJhe�e �vas ihe device instalied (generai description, attaeh map)? L�(--�— �'f ��� <br />,. <br />VJas there any other sewer or storm drainage work compl�led in cofjun�lion erith ihe fiWD eaork? Is so please describe: _ <br />Inst�llation Cheeklist: <br />Are all dovrnspouts and site drainage dlsc�nnecled from upstream of Ihe BVJD? [�Yes ❑ No Comments: <br />Does �WD positioning meets minimum slope requirementof>1%7 }� Yes ❑ No Commenis — <br />Can aWD be pulled out for inspection and maintenance after loosening thumb s�rew? �j Yes L] No <br />Is BWD locked inlo tf;e p�e osition and Ihum'scr �vGghlened7 �1 Yes ❑ No <br />Circle the BtiVD cove�m�gaGon eover (landscape area)1 (fic load bearing cove- (drive surface)1 access hatch (buliding) <br />VJas property owner shownitteiocaliorwk ns alled Bl-VD? �] Yes ❑ No Commenis: _ <br />Properiy Ov;ner's 5ignature: _ <br />Installers Signature: <br />Date: <br />Dale: �/ — � � �� <br />Revision: 7. 1 Friday, Sepicmbcr 12, 2014 <br />